1
|
Hum C, Tahir U, Mei SHJ, Champagne J, Fergusson DA, Lalu M, Stewart DJ, Walley K, Marshall J, dos Santos CC, Winston BW, Mendelson AA, Dave C, McIntyre L. Efficacy and Safety of Umbilical Cord-Derived Mesenchymal Stromal Cell Therapy in Preclinical Models of Sepsis: A Systematic Review and Meta-analysis. Stem Cells Transl Med 2024; 13:346-361. [PMID: 38381583 PMCID: PMC11016835 DOI: 10.1093/stcltm/szae003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 11/11/2023] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND In preclinical studies, mesenchymal stromal cells (MSCs), including umbilical cord-derived MSCs (UC-MSCs), demonstrate the ability to modulate numerous pathophysiological processes related to sepsis; however, a systematic synthesis of the literature is needed to assess the efficacy of UC-MSCs for treating sepsis. OBJECTIVE To examine the effects of UC-MSCs on overall mortality (primary outcome) as well as on organ dysfunction, coagulopathy, endothelial permeability, pathogen clearance, and systemic inflammation (secondary outcomes) at prespecified time intervals in preclinical models of sepsis. METHODS A systematic search was conducted on Embase, Ovid MEDLINE, and Web of Science up to June 20, 2023. Preclinical controlled studies using in vivo sepsis models with systemic UC-MSC administration were included. Meta-analyses were conducted and expressed as odds ratios (OR) and ratios of the weighted means with 95% CI for categorical and continuous data, respectively. Risk of bias was assessed with the SYRCLE tool. RESULTS Twenty-six studies (34 experiments, n = 1258 animals) were included in this review. Overall mortality was significantly reduced with UC-MSC treatment as compared to controls (OR: 0.26, 95% CI: 0.18-0.36). At various prespecified time intervals, UC-MSCs reduced surrogate measures of organ dysfunction related to the kidney, liver, and lung; reduced coagulopathy and endothelial permeability; and enhanced pathogen clearance from multiple sites. UC-MSCs also modulated systemic inflammatory mediators. No studies were rated as low risk across all SYCLE domains. CONCLUSIONS These results demonstrate the efficacy of UC-MSC treatment in preclinical sepsis models and highlight their potential as a therapeutic intervention for septic shock.
Collapse
Affiliation(s)
- Christine Hum
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Usama Tahir
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Shirley H J Mei
- Regenerative Medicine Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Josee Champagne
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Manoj Lalu
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Regenerative Medicine Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Cell and Molecular Medicine, University of Ottawa, Ottawa, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Ottawa, The Ottawa Hospital, Ottawa, ON, Canada
| | - Duncan J Stewart
- Regenerative Medicine Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Cell and Molecular Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Keith Walley
- Department of Medicine, Centre for Heart Lung Innovation, University of British Columbia, Vancouver, BC, Canada
| | - John Marshall
- Department of Surgery (Critical Care), University of Toronto, Toronto, ON, Canada
| | - Claudia C dos Santos
- Keenan Research Centre for Biomedical Science and Interdepartmental Division of Critical Care, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada
| | - Brent W Winston
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
| | - Asher A Mendelson
- Section of Critical Care Medicine, Department of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Chintan Dave
- Division of Critical Care Medicine, Department of Medicine, Western University, London, ON, Canada
| | - Lauralyn McIntyre
- Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine (Division of Critical Care), University of Ottawa, Ottawa, ON, Canada
- Department of Medicine (Critical Care), The Ottawa Hospital, Ottawa Hospital Research Institute, Centre for Transfusion and Critical Care Research, Ottawa, ON, Canada
| |
Collapse
|
2
|
O'Hearn K, Menon K, Weiler HA, Amrein K, Fergusson D, Gunz A, Bustos R, Campos R, Catalan V, Roedl S, Tsampalieros A, Barrowman N, Geier P, Henderson M, Khamessan A, Lawson ML, McIntyre L, Redpath S, Jones G, Kaufmann M, McNally D. A phase II dose evaluation pilot feasibility randomized controlled trial of cholecalciferol in critically ill children with vitamin D deficiency (VITdAL-PICU study). BMC Pediatr 2023; 23:397. [PMID: 37580663 PMCID: PMC10424361 DOI: 10.1186/s12887-023-04205-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 07/24/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND Vitamin D deficiency (VDD) is highly prevalent in the pediatric intensive care unit (ICU) and associated with worse clinical course. Trials in adult ICU demonstrate rapid restoration of vitamin D status using an enteral loading dose is safe and may improve outcomes. There have been no published trials of rapid normalization of VDD in the pediatric ICU. METHODS We conducted a multicenter placebo-controlled phase II pilot feasibility randomized clinical trial from 2016 to 2017. We randomized 67 critically ill children with VDD from ICUs in Canada, Chile and Austria using a 2:1 randomization ratio to receive a loading dose of enteral cholecalciferol (10,000 IU/kg, maximum of 400,000 IU) or placebo. Participants, care givers, and outcomes assessors were blinded. The primary objective was to determine whether the loading dose normalized vitamin D status (25(OH)D > 75 nmol/L). Secondary objectives were to evaluate for adverse events and assess the feasibility of a phase III trial. RESULTS Of 67 randomized participants, one was withdrawn and seven received more than one dose of cholecalciferol before the protocol was amended to a single loading dose, leaving 59 participants in the primary analyses (40 treatment, 19 placebo). Thirty-one/38 (81.6%) participants in the treatment arm achieved a plasma 25(OH)D concentration > 75 nmol/L versus 1/18 (5.6%) the placebo arm. The mean 25(OH)D concentration in the treatment arm was 125.9 nmol/L (SD 63.4). There was no evidence of vitamin D toxicity and no major drug or safety protocol violations. The accrual rate was 3.4 patients/month, supporting feasibility of a larger trial. A day 7 blood sample was collected for 84% of patients. A survey administered to 40 participating families showed that health-related quality of life (HRQL) was the most important outcome for families for the main trial (30, 75%). CONCLUSIONS A single 10,000 IU/kg dose can rapidly and safely normalize plasma 25(OH)D concentrations in critically ill children with VDD, but with significant variability in 25(OH)D concentrations. We established that a phase III multicentre trial is feasible. Using an outcome collected after hospital discharge (HRQL) will require strategies to minimize loss-to-follow-up. TRIAL REGISTRATION CLINICALTRIALS gov NCT02452762 Registered 25/05/2015.
Collapse
Affiliation(s)
- Katie O'Hearn
- Research Institute, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Kusum Menon
- Research Institute, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Hope A Weiler
- School of Human Nutrition, Faculty of Agricultural and Environmental Sciences, McGill University, Montreal, Canada
| | - Karin Amrein
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Dean Fergusson
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Anna Gunz
- Department of Paediatrics, Schulich School of Medicine & Dentistry, Western University, London, ON, N6A 5W9, Canada
- Child Health Research Institute, London, ON, N6A 5W9, Canada
| | - Raul Bustos
- Clínica Sanatorio Alemán, Unidad de Cuidados Intensivos Pediátricos, Concepción, Chile
- Facultad de Medicine Y Ciencia, UCI Pediátrica Hospital Guillermo Grant Benavente Concepción, Universidad San Sebastián, Concepción, Chile
| | - Roberto Campos
- Clínica Sanatorio Alemán, Unidad de Cuidados Intensivos Pediátricos, Concepción, Chile
| | - Valentina Catalan
- Clínica Sanatorio Alemán, Unidad de Cuidados Intensivos Pediátricos, Concepción, Chile
| | - Siegfried Roedl
- Department of Paediatrics and Adolescent Medicine, Joint Facilities, Medical University of Graz, Graz, Austria
| | - Anne Tsampalieros
- Clinical Research Unit, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Nick Barrowman
- Clinical Research Unit, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Pavel Geier
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Matthew Henderson
- Research Institute, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Newborn Screening Ontario, Ottawa, Canada
| | - Ali Khamessan
- Euro-Pharm International Canada Inc, Montreal, Canada
| | - Margaret L Lawson
- Research Institute, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Canada
- Division of Endocrinology, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Lauralyn McIntyre
- Department of Medicine (Division of Critical Care), Ottawa Hospital Research Institute (OHRI), University of Ottawa, Ottawa, Canada
| | - Stephanie Redpath
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Canada
| | - Glenville Jones
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Canada
| | - Martin Kaufmann
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Canada
| | - Dayre McNally
- Research Institute, Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada.
- Department of Pediatrics, Faculty of Medicine, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Canada.
| |
Collapse
|
3
|
Terrett LA, McIntyre L, Turgeon AF, English SW. Anemia and Red Blood Cell Transfusion in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:91-103. [PMID: 37634181 DOI: 10.1007/s12028-023-01815-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 07/13/2023] [Indexed: 08/29/2023]
Abstract
Anemia is very common in aneurysmal subarachnoid hemorrhage (aSAH), with approximately half of the aSAH patient population developing moderate anemia during their hospital stay. The available evidence (both physiologic and clinical) generally supports an association of anemia with unfavorable outcomes. Although aSAH shares a number of common mechanisms of secondary insult with other forms of acute brain injury, aSAH also has specific features that make it unique: an early phase (in which early brain injury predominates) and a delayed phase (in which delayed cerebral ischemia and vasospasm predominate). The effects of both anemia and transfusion are potentially variable between these phases, which may have unique considerations and possibly different risk-benefit profiles. Data on transfusion in this population are almost exclusively limited to observational studies, which suffer from significant heterogeneity and risk of bias. Overall, the results are conflicting, with the balance of the studies suggesting that transfusion is associated with unfavorable outcomes. The transfusion targets that are well established in other critically ill populations should not be automatically applied to patients with aSAH because of the unique disease characteristics of this population and the limited representation of aSAH in the clinical trials that established these targets. There are two upcoming clinical trials evaluating transfusion in aSAH that should help clarify specific transfusion targets. Until then, it is reasonable to base transfusion decisions on the current guidelines and use an individualized approach incorporating physiologic and clinical data when available.
Collapse
Affiliation(s)
- Luke A Terrett
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
- Department of Adult Critical Care, Saskatchewan Health Authority, Saskatoon, SK, Canada
| | - Lauralyn McIntyre
- Department of Medicine (Critical Care), University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program (CEP), Ottawa Hospital Research Institute (OHRI), Civic Campus Room F202, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada
- The Ottawa Hospital, Ottawa, ON, Canada
| | - Alexis F Turgeon
- Department of Anesthesiology and Critical Care Medicine, Université Laval, Quebec City, QC, Canada
- Population Health and Optimal Health Practices Unit, Centre hospitalier universitaire de Québec-Université Laval Research Center, Quebec City, QC, Canada
| | - Shane W English
- Department of Medicine (Critical Care), University of Ottawa, Ottawa, ON, Canada.
- Clinical Epidemiology Program (CEP), Ottawa Hospital Research Institute (OHRI), Civic Campus Room F202, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada.
- The Ottawa Hospital, Ottawa, ON, Canada.
| |
Collapse
|
4
|
Tran A, Saigle V, Manhas N, McIntyre L, Turgeon AF, Lauzier F, Chassé M, Golka C, Millington SJ, Kyeremanteng K, Ghinda D, Lesiuk H, Kanji S, Fairbairn J, Lloyd T, English SW. Association of age with death and withdrawal of life-sustaining therapy after severe traumatic brain injury. Can J Surg 2023; 66:E348-E355. [PMID: 37402559 DOI: 10.1503/cjs.013721] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/31/2022] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND Compared to younger age, older age (≥ 65 yr) is associated with worse outcomes after severe traumatic brain injury (TBI). We sought to describe the association of older age with in-hospital death and aggressiveness of intervention. METHODS We conducted a retrospective cohort study of adult (age ≥ 16 yr) patients with severe TBI admitted to a single academic tertiary care neurotrauma centre between January 2014 and December 2015. We collected data through chart review as well as from our institutional administrative database. We provided descriptive statistics and used multivariable logistic regression to evaluate the independent association of age with the primary outcome, in-hospital death. The secondary outcome was early withdrawal of life-sustaining therapy. RESULTS There were 126 adult patients (median age 67 yr [Q1-Q3, 33-80 yr]) with severe TBI during the study period who met our eligibility criteria. The most common mechanism was high-velocity blunt injury (55 patients [43.6%]). The median Marshall score was 4 (Q1-Q3, 2-6), and the median Injury Severity Score was 26 (Q1-Q3, 25-35). After controlling for confounders including clinical frailty, pre-existing comorbidity, injury severity, Marshall score and neurologic examination at admission, we observed that older patients were more likely than younger patients to die in hospital (odds ratio 5.10, 95% confidence interval 1.65-15.78). Older patients were also more likely to experience early withdrawal of life-sustaining therapy and less likely to receive invasive interventions. CONCLUSION After controlling for confounding factors relevant to older patients, we observed that age was an important and independent predictor of in-hospital death and early withdrawal of life-sustaining therapy. The mechanism by which age influences clinical decision-making independent of global and neurologic injury severity, clinical frailty and comorbidities remains unclear.
Collapse
Affiliation(s)
- Alexandre Tran
- From the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Tran, Saigle, McIntyre, Kanji, English); the Department of Medicine (Critical Care), University of Ottawa, Ottawa, Ont. (Tran, McIntyre, Golka, Millington, Kyeremanteng, Kanji, Fairbairn, Lloyd, English); the Department of Surgery, University of Ottawa, Ottawa, Ont. (Tran, Ghinda, Lesiuk); the Department of Surgery, University of British Columbia, Vancouver, BC (Manhas); the Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec, Que. (Turgeon, Lauzier); the Department of Medicine, Université Laval, Québec, Que. (Lauzier); the CHU de Québec-Université Laval Research Centre, Population Health and Optimal Health Practices Unit, Trauma - Emergency - Critical Care Medicine, Québec, Que. (Turgeon); the Innovation Hub, Centre hospitalier de l'Université de Montréal Research Centre, Montréal, Que. (Chassé); and the Department of Pharmacy, University of Ottawa, Ottawa, Ont. (Kanji)
| | - Victoria Saigle
- From the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Tran, Saigle, McIntyre, Kanji, English); the Department of Medicine (Critical Care), University of Ottawa, Ottawa, Ont. (Tran, McIntyre, Golka, Millington, Kyeremanteng, Kanji, Fairbairn, Lloyd, English); the Department of Surgery, University of Ottawa, Ottawa, Ont. (Tran, Ghinda, Lesiuk); the Department of Surgery, University of British Columbia, Vancouver, BC (Manhas); the Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec, Que. (Turgeon, Lauzier); the Department of Medicine, Université Laval, Québec, Que. (Lauzier); the CHU de Québec-Université Laval Research Centre, Population Health and Optimal Health Practices Unit, Trauma - Emergency - Critical Care Medicine, Québec, Que. (Turgeon); the Innovation Hub, Centre hospitalier de l'Université de Montréal Research Centre, Montréal, Que. (Chassé); and the Department of Pharmacy, University of Ottawa, Ottawa, Ont. (Kanji)
| | - Neraj Manhas
- From the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Tran, Saigle, McIntyre, Kanji, English); the Department of Medicine (Critical Care), University of Ottawa, Ottawa, Ont. (Tran, McIntyre, Golka, Millington, Kyeremanteng, Kanji, Fairbairn, Lloyd, English); the Department of Surgery, University of Ottawa, Ottawa, Ont. (Tran, Ghinda, Lesiuk); the Department of Surgery, University of British Columbia, Vancouver, BC (Manhas); the Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec, Que. (Turgeon, Lauzier); the Department of Medicine, Université Laval, Québec, Que. (Lauzier); the CHU de Québec-Université Laval Research Centre, Population Health and Optimal Health Practices Unit, Trauma - Emergency - Critical Care Medicine, Québec, Que. (Turgeon); the Innovation Hub, Centre hospitalier de l'Université de Montréal Research Centre, Montréal, Que. (Chassé); and the Department of Pharmacy, University of Ottawa, Ottawa, Ont. (Kanji)
| | - Lauralyn McIntyre
- From the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Tran, Saigle, McIntyre, Kanji, English); the Department of Medicine (Critical Care), University of Ottawa, Ottawa, Ont. (Tran, McIntyre, Golka, Millington, Kyeremanteng, Kanji, Fairbairn, Lloyd, English); the Department of Surgery, University of Ottawa, Ottawa, Ont. (Tran, Ghinda, Lesiuk); the Department of Surgery, University of British Columbia, Vancouver, BC (Manhas); the Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec, Que. (Turgeon, Lauzier); the Department of Medicine, Université Laval, Québec, Que. (Lauzier); the CHU de Québec-Université Laval Research Centre, Population Health and Optimal Health Practices Unit, Trauma - Emergency - Critical Care Medicine, Québec, Que. (Turgeon); the Innovation Hub, Centre hospitalier de l'Université de Montréal Research Centre, Montréal, Que. (Chassé); and the Department of Pharmacy, University of Ottawa, Ottawa, Ont. (Kanji)
| | - Alexis F Turgeon
- From the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Tran, Saigle, McIntyre, Kanji, English); the Department of Medicine (Critical Care), University of Ottawa, Ottawa, Ont. (Tran, McIntyre, Golka, Millington, Kyeremanteng, Kanji, Fairbairn, Lloyd, English); the Department of Surgery, University of Ottawa, Ottawa, Ont. (Tran, Ghinda, Lesiuk); the Department of Surgery, University of British Columbia, Vancouver, BC (Manhas); the Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec, Que. (Turgeon, Lauzier); the Department of Medicine, Université Laval, Québec, Que. (Lauzier); the CHU de Québec-Université Laval Research Centre, Population Health and Optimal Health Practices Unit, Trauma - Emergency - Critical Care Medicine, Québec, Que. (Turgeon); the Innovation Hub, Centre hospitalier de l'Université de Montréal Research Centre, Montréal, Que. (Chassé); and the Department of Pharmacy, University of Ottawa, Ottawa, Ont. (Kanji)
| | - François Lauzier
- From the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Tran, Saigle, McIntyre, Kanji, English); the Department of Medicine (Critical Care), University of Ottawa, Ottawa, Ont. (Tran, McIntyre, Golka, Millington, Kyeremanteng, Kanji, Fairbairn, Lloyd, English); the Department of Surgery, University of Ottawa, Ottawa, Ont. (Tran, Ghinda, Lesiuk); the Department of Surgery, University of British Columbia, Vancouver, BC (Manhas); the Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec, Que. (Turgeon, Lauzier); the Department of Medicine, Université Laval, Québec, Que. (Lauzier); the CHU de Québec-Université Laval Research Centre, Population Health and Optimal Health Practices Unit, Trauma - Emergency - Critical Care Medicine, Québec, Que. (Turgeon); the Innovation Hub, Centre hospitalier de l'Université de Montréal Research Centre, Montréal, Que. (Chassé); and the Department of Pharmacy, University of Ottawa, Ottawa, Ont. (Kanji)
| | - Michael Chassé
- From the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Tran, Saigle, McIntyre, Kanji, English); the Department of Medicine (Critical Care), University of Ottawa, Ottawa, Ont. (Tran, McIntyre, Golka, Millington, Kyeremanteng, Kanji, Fairbairn, Lloyd, English); the Department of Surgery, University of Ottawa, Ottawa, Ont. (Tran, Ghinda, Lesiuk); the Department of Surgery, University of British Columbia, Vancouver, BC (Manhas); the Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec, Que. (Turgeon, Lauzier); the Department of Medicine, Université Laval, Québec, Que. (Lauzier); the CHU de Québec-Université Laval Research Centre, Population Health and Optimal Health Practices Unit, Trauma - Emergency - Critical Care Medicine, Québec, Que. (Turgeon); the Innovation Hub, Centre hospitalier de l'Université de Montréal Research Centre, Montréal, Que. (Chassé); and the Department of Pharmacy, University of Ottawa, Ottawa, Ont. (Kanji)
| | - Colleen Golka
- From the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Tran, Saigle, McIntyre, Kanji, English); the Department of Medicine (Critical Care), University of Ottawa, Ottawa, Ont. (Tran, McIntyre, Golka, Millington, Kyeremanteng, Kanji, Fairbairn, Lloyd, English); the Department of Surgery, University of Ottawa, Ottawa, Ont. (Tran, Ghinda, Lesiuk); the Department of Surgery, University of British Columbia, Vancouver, BC (Manhas); the Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec, Que. (Turgeon, Lauzier); the Department of Medicine, Université Laval, Québec, Que. (Lauzier); the CHU de Québec-Université Laval Research Centre, Population Health and Optimal Health Practices Unit, Trauma - Emergency - Critical Care Medicine, Québec, Que. (Turgeon); the Innovation Hub, Centre hospitalier de l'Université de Montréal Research Centre, Montréal, Que. (Chassé); and the Department of Pharmacy, University of Ottawa, Ottawa, Ont. (Kanji)
| | - Scott J Millington
- From the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Tran, Saigle, McIntyre, Kanji, English); the Department of Medicine (Critical Care), University of Ottawa, Ottawa, Ont. (Tran, McIntyre, Golka, Millington, Kyeremanteng, Kanji, Fairbairn, Lloyd, English); the Department of Surgery, University of Ottawa, Ottawa, Ont. (Tran, Ghinda, Lesiuk); the Department of Surgery, University of British Columbia, Vancouver, BC (Manhas); the Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec, Que. (Turgeon, Lauzier); the Department of Medicine, Université Laval, Québec, Que. (Lauzier); the CHU de Québec-Université Laval Research Centre, Population Health and Optimal Health Practices Unit, Trauma - Emergency - Critical Care Medicine, Québec, Que. (Turgeon); the Innovation Hub, Centre hospitalier de l'Université de Montréal Research Centre, Montréal, Que. (Chassé); and the Department of Pharmacy, University of Ottawa, Ottawa, Ont. (Kanji)
| | - Kwadwo Kyeremanteng
- From the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Tran, Saigle, McIntyre, Kanji, English); the Department of Medicine (Critical Care), University of Ottawa, Ottawa, Ont. (Tran, McIntyre, Golka, Millington, Kyeremanteng, Kanji, Fairbairn, Lloyd, English); the Department of Surgery, University of Ottawa, Ottawa, Ont. (Tran, Ghinda, Lesiuk); the Department of Surgery, University of British Columbia, Vancouver, BC (Manhas); the Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec, Que. (Turgeon, Lauzier); the Department of Medicine, Université Laval, Québec, Que. (Lauzier); the CHU de Québec-Université Laval Research Centre, Population Health and Optimal Health Practices Unit, Trauma - Emergency - Critical Care Medicine, Québec, Que. (Turgeon); the Innovation Hub, Centre hospitalier de l'Université de Montréal Research Centre, Montréal, Que. (Chassé); and the Department of Pharmacy, University of Ottawa, Ottawa, Ont. (Kanji)
| | - Diana Ghinda
- From the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Tran, Saigle, McIntyre, Kanji, English); the Department of Medicine (Critical Care), University of Ottawa, Ottawa, Ont. (Tran, McIntyre, Golka, Millington, Kyeremanteng, Kanji, Fairbairn, Lloyd, English); the Department of Surgery, University of Ottawa, Ottawa, Ont. (Tran, Ghinda, Lesiuk); the Department of Surgery, University of British Columbia, Vancouver, BC (Manhas); the Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec, Que. (Turgeon, Lauzier); the Department of Medicine, Université Laval, Québec, Que. (Lauzier); the CHU de Québec-Université Laval Research Centre, Population Health and Optimal Health Practices Unit, Trauma - Emergency - Critical Care Medicine, Québec, Que. (Turgeon); the Innovation Hub, Centre hospitalier de l'Université de Montréal Research Centre, Montréal, Que. (Chassé); and the Department of Pharmacy, University of Ottawa, Ottawa, Ont. (Kanji)
| | - Howard Lesiuk
- From the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Tran, Saigle, McIntyre, Kanji, English); the Department of Medicine (Critical Care), University of Ottawa, Ottawa, Ont. (Tran, McIntyre, Golka, Millington, Kyeremanteng, Kanji, Fairbairn, Lloyd, English); the Department of Surgery, University of Ottawa, Ottawa, Ont. (Tran, Ghinda, Lesiuk); the Department of Surgery, University of British Columbia, Vancouver, BC (Manhas); the Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec, Que. (Turgeon, Lauzier); the Department of Medicine, Université Laval, Québec, Que. (Lauzier); the CHU de Québec-Université Laval Research Centre, Population Health and Optimal Health Practices Unit, Trauma - Emergency - Critical Care Medicine, Québec, Que. (Turgeon); the Innovation Hub, Centre hospitalier de l'Université de Montréal Research Centre, Montréal, Que. (Chassé); and the Department of Pharmacy, University of Ottawa, Ottawa, Ont. (Kanji)
| | - Salmaan Kanji
- From the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Tran, Saigle, McIntyre, Kanji, English); the Department of Medicine (Critical Care), University of Ottawa, Ottawa, Ont. (Tran, McIntyre, Golka, Millington, Kyeremanteng, Kanji, Fairbairn, Lloyd, English); the Department of Surgery, University of Ottawa, Ottawa, Ont. (Tran, Ghinda, Lesiuk); the Department of Surgery, University of British Columbia, Vancouver, BC (Manhas); the Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec, Que. (Turgeon, Lauzier); the Department of Medicine, Université Laval, Québec, Que. (Lauzier); the CHU de Québec-Université Laval Research Centre, Population Health and Optimal Health Practices Unit, Trauma - Emergency - Critical Care Medicine, Québec, Que. (Turgeon); the Innovation Hub, Centre hospitalier de l'Université de Montréal Research Centre, Montréal, Que. (Chassé); and the Department of Pharmacy, University of Ottawa, Ottawa, Ont. (Kanji)
| | - Jennifer Fairbairn
- From the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Tran, Saigle, McIntyre, Kanji, English); the Department of Medicine (Critical Care), University of Ottawa, Ottawa, Ont. (Tran, McIntyre, Golka, Millington, Kyeremanteng, Kanji, Fairbairn, Lloyd, English); the Department of Surgery, University of Ottawa, Ottawa, Ont. (Tran, Ghinda, Lesiuk); the Department of Surgery, University of British Columbia, Vancouver, BC (Manhas); the Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec, Que. (Turgeon, Lauzier); the Department of Medicine, Université Laval, Québec, Que. (Lauzier); the CHU de Québec-Université Laval Research Centre, Population Health and Optimal Health Practices Unit, Trauma - Emergency - Critical Care Medicine, Québec, Que. (Turgeon); the Innovation Hub, Centre hospitalier de l'Université de Montréal Research Centre, Montréal, Que. (Chassé); and the Department of Pharmacy, University of Ottawa, Ottawa, Ont. (Kanji)
| | - Tammy Lloyd
- From the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Tran, Saigle, McIntyre, Kanji, English); the Department of Medicine (Critical Care), University of Ottawa, Ottawa, Ont. (Tran, McIntyre, Golka, Millington, Kyeremanteng, Kanji, Fairbairn, Lloyd, English); the Department of Surgery, University of Ottawa, Ottawa, Ont. (Tran, Ghinda, Lesiuk); the Department of Surgery, University of British Columbia, Vancouver, BC (Manhas); the Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec, Que. (Turgeon, Lauzier); the Department of Medicine, Université Laval, Québec, Que. (Lauzier); the CHU de Québec-Université Laval Research Centre, Population Health and Optimal Health Practices Unit, Trauma - Emergency - Critical Care Medicine, Québec, Que. (Turgeon); the Innovation Hub, Centre hospitalier de l'Université de Montréal Research Centre, Montréal, Que. (Chassé); and the Department of Pharmacy, University of Ottawa, Ottawa, Ont. (Kanji)
| | - Shane W English
- From the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Tran, Saigle, McIntyre, Kanji, English); the Department of Medicine (Critical Care), University of Ottawa, Ottawa, Ont. (Tran, McIntyre, Golka, Millington, Kyeremanteng, Kanji, Fairbairn, Lloyd, English); the Department of Surgery, University of Ottawa, Ottawa, Ont. (Tran, Ghinda, Lesiuk); the Department of Surgery, University of British Columbia, Vancouver, BC (Manhas); the Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec, Que. (Turgeon, Lauzier); the Department of Medicine, Université Laval, Québec, Que. (Lauzier); the CHU de Québec-Université Laval Research Centre, Population Health and Optimal Health Practices Unit, Trauma - Emergency - Critical Care Medicine, Québec, Que. (Turgeon); the Innovation Hub, Centre hospitalier de l'Université de Montréal Research Centre, Montréal, Que. (Chassé); and the Department of Pharmacy, University of Ottawa, Ottawa, Ont. (Kanji)
| |
Collapse
|
5
|
Tan Y, Wang Y, Souza-Moreira L, Wang C, Murray ABP, Salkhordeh M, Florian M, McIntyre L, Stewart DJ, Mei SHJ. Mesenchymal stem cells induce dynamic immunomodulation of airway and systemic immune cells in vivo but do not improve survival for mice with H1N1 virus-induced acute lung injury. Front Bioeng Biotechnol 2023; 11:1203387. [PMID: 37362215 PMCID: PMC10285296 DOI: 10.3389/fbioe.2023.1203387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 05/25/2023] [Indexed: 06/28/2023] Open
Abstract
Introduction: Influenza A virus (IAV)-induced acute lung injury (ALI) is characterized by pronounced proinflammatory activation and respiratory lung dysfunction. In this study, we performed deep immune profiling on airway and circulating immune cells to examine the effect of immunomodulation and therapeutic outcomes of mesenchymal stem cells (MSCs) therapy in mice with IAV-induced ALI. Methods: Animals were inoculated intranasally with H1N1 IAV, followed by intravenous administration of vehicle, or human clinical-grade, bone marrow-derived MSCs 24-h later, and monitored for six days to evaluate the survival. In another set of animals, bronchoalveolar lavage (BAL) fluid and whole blood were collected three days after infection for flow or mass cytometry (CyTOF) immune profiling analysis. Results: Immune cell population and phenotypic shifts in blood were mapped by CyTOF. Increases were observed in granulocytes and myeloid-derived cells in blood from vehicle-treated animals. While MSC treatment accentuated changes in these populations, naïve B, antibody-secreting B cells, and T cells were decreased in MSC-treated animals at day 3. Compared to sham animals, IAV infection induced a significant 5.5-fold increase in BAL total cell counts, including CD4+ and CD8+ T cells, CD19+ B cells, CD11b + Ly6G + neutrophils, and CD11b + Ly6C + monocytes. MSC treatment significantly decreased BAL total cell counts in IAV-infected mice, specifically the number of infiltrating CD4+ T cells and CD11b + Ly6G + neutrophils. In contrast, there were increases in CD8+ T cells, B cells, and monocytes in the alveolar space in MSC-treated animals. Phenotypic immune cell profiling of blood and BAL revealed a significantly higher proportion of the monocyte population with the M2 phenotype (CD206) in MSC-treated animals; however, this failed to confer protective effects in the survival of infected mice or reduce viral titer in the lung. Further investigation revealed that MSCs were susceptible to IAV infection, leading to increased cell death and potentially affecting their efficacy. Conclusion: These findings provided in vivo evidence that MSCs promote the selective recruitment of immune cells to the site of infection during IAV infection, with reductions in proinflammatory phenotypes. However, MSCs offered no survival benefit in IAV-infected animals, possibly due to MSCs' H1N1 IAV susceptibility and subsequent cell death.
Collapse
Affiliation(s)
- Yuan Tan
- Regenerative Medicine Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Yan Wang
- Regenerative Medicine Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Luciana Souza-Moreira
- Regenerative Medicine Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Chi Wang
- Regenerative Medicine Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Aidan B. P. Murray
- Regenerative Medicine Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Mahmoud Salkhordeh
- Regenerative Medicine Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Maria Florian
- Regenerative Medicine Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Lauralyn McIntyre
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Duncan J. Stewart
- Regenerative Medicine Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Shirley H. J. Mei
- Regenerative Medicine Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| |
Collapse
|
6
|
Neves Briard J, Nitulescu R, Lemoine É, Titova P, McIntyre L, English SW, Knoll G, Shemie SD, Martin C, Turgeon AF, Lauzier F, Fergusson DA, Chassé M. Diagnostic accuracy of ancillary tests for death by neurologic criteria: a systematic review and meta-analysis. Can J Anaesth 2023; 70:736-748. [PMID: 37155120 PMCID: PMC10202988 DOI: 10.1007/s12630-023-02426-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/20/2022] [Accepted: 10/21/2022] [Indexed: 05/10/2023] Open
Abstract
PURPOSE Ancillary tests are frequently used in death determination by neurologic criteria (DNC), particularly when the clinical neurologic examination is unreliable. Nevertheless, their diagnostic accuracy has not been extensively studied. Our objective was to synthesize the sensitivity and specificity of commonly used ancillary tests for DNC. SOURCE We performed a systematic review and meta-analysis by searching MEDLINE, EMBASE, Cochrane databases, and CINAHL Ebsco from their inception to 4 February 2022. We selected cohort and case-control studies including patients with 1) clinically diagnosed death by neurologic criteria or 2) clinically suspected death by neurologic criteria who underwent ancillary testing for DNC. We excluded studies without a priori diagnostic criteria and studies conducted solely on pediatric patients. Accepted reference standards were clinical examination, four-vessel conventional angiography, and radionuclide imaging. Data were directly extracted from published reports. We assessed the methodological quality of studies with the QUADAS-2 tool and estimated ancillary test sensitivities and specificities using hierarchical Bayesian models with diffuse priors. PRINCIPAL FINDINGS Overall, 137 records met the selection criteria. One study (0.7%) had a low risk of bias in all QUADAS-2 domains. Among clinically diagnosed death by neurologic criteria patients (n = 8,891), ancillary tests had similar pooled sensitivities (range, 0.82-0.93). Sensitivity heterogeneity was greater within (σ = 0.10-0.15) than between (σ = 0.04) ancillary test types. Among clinically suspected death by neurologic criteria patients (n = 2,732), pooled ancillary test sensitivities ranged between 0.81 and 1.00 and specificities between 0.87 and 1.00. Most estimates had high statistical uncertainty. CONCLUSION Studies assessing ancillary test diagnostic accuracy have an unclear or high risk of bias. High-quality studies are required to thoroughly validate ancillary tests for DNC. STUDY REGISTRATION PROSPERO (CRD42013005907); registered 7 October 2013.
Collapse
Affiliation(s)
- Joel Neves Briard
- Department of Neuroscience, Université de Montréal, Montreal, QC, Canada
- Centre de recherche du Centre hospitalier de l'Université de Montréal, 900 rue Saint-Denis, Montreal, QC, H2X 3H8, Canada
| | - Roy Nitulescu
- Centre de recherche du Centre hospitalier de l'Université de Montréal, 900 rue Saint-Denis, Montreal, QC, H2X 3H8, Canada
| | - Émile Lemoine
- Department of Neuroscience, Université de Montréal, Montreal, QC, Canada
| | - Polina Titova
- Centre de recherche du Centre hospitalier de l'Université de Montréal, 900 rue Saint-Denis, Montreal, QC, H2X 3H8, Canada
| | - Lauralyn McIntyre
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Shane W English
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Greg Knoll
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Sam D Shemie
- Department of Pediatrics, McGill University, Montreal, QC, Canada
| | - Claudio Martin
- Department of Medicine, Schulich School of Medicine and Dentistry, London, ON, Canada
| | - Alexis F Turgeon
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Quebec City, QC, Canada
- Population Health and Optimal Health Practices Research Unit (Trauma-Emergency-Critical Care Medicine), CHU de Québec-Université Laval Research Center, Quebec City, QC, Canada
| | - François Lauzier
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Quebec City, QC, Canada
- Population Health and Optimal Health Practices Research Unit (Trauma-Emergency-Critical Care Medicine), CHU de Québec-Université Laval Research Center, Quebec City, QC, Canada
- Department of Medicine, Université Laval, Quebec City, QC, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Michaël Chassé
- Centre de recherche du Centre hospitalier de l'Université de Montréal, 900 rue Saint-Denis, Montreal, QC, H2X 3H8, Canada.
- Department of Medicine, Université de Montréal, Montreal, QC, Canada.
| |
Collapse
|
7
|
Niznick N, Saigle V, Marti ML, Laframboise J, Zha X, Andersen C, Presseau J, Chassé M, McIntyre L, Fergusson D, Turgeon AF, Lauzier F, Mayer SA, Lahiri S, Ramsay T, English S. Patient Relevance of the Modified Rankin Scale in Subarachnoid Hemorrhage Research: An International Cross-sectional Survey. Neurology 2023; 100:e1565-e1573. [PMID: 36750387 PMCID: PMC10103120 DOI: 10.1212/wnl.0000000000206879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 12/15/2022] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND AND OBJECTIVES There is significant heterogeneity in the reporting of outcomes measure in aneurysmal subarachnoid hemorrhage (aSAH) research. The modified Rankin Scale (mRS) is the most commonly reported functional outcome measure. The mRS focuses on physical disability, however many aSAH survivors experience sequalae in other domains, and the mRS may therefore not capture outcomes important to aSAH survivors. The objective of this study was to assess the clinical relevance of the mRS as a research outcome measure to people with lived aSAH. METHODS We conducted an international cross-sectional survey of 355 aSAH survivors, family members and caregivers to evaluate patient-perceived outcomes in relation to the mRS. The mRS was assessed using a previously validated web-based tool. RESULTS Response rate was 60%; respondents from 7 continents were comprised of 86% aSAH survivors and 14% family members/caregivers. Agreement between self-assessed outcome and the mRS was poor (Kappa 0.26 (CI 0.14-0.39)). Of the 172 respondents who self-assessed as having had a good aSAH outcome, 122 (71%) had a score of 0-2 on the mRS. 19% of respondents with a good outcome, based on a measured mRS score of 0-2, self-assessed as having had a poor aSAH outcome. When the mRS score was dichotomized as 0-3 corresponding to a good outcome, agreement between the score and self-assessed outcome remained poor with a Kappa score of 0.40 (CI 0.20-0.60). Thirty per cent of respondents felt that the mRS should not be used as an outcome measure in future aSAH trials. DISCUSSION The findings suggest that there is poor agreement between aSAH survivors' self-assessed outcome, their actual mRS score and the dichotomization of the mRS score into good/poor outcomes. Patient-centered and -informed outcome measurement tools are needed to guide the aSAH research agenda.
Collapse
Affiliation(s)
- Naomi Niznick
- Department of Medicine (Neurology), The Ottawa Hospital, Ottawa, ON, Canada
| | - Victoria Saigle
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Canada
| | - Maria Luisa Marti
- Patient partner, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Canada
| | - Josephine Laframboise
- Patient partner, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Canada
| | - Xiaohui Zha
- Patient partner, Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Canada
| | - Chris Andersen
- The George Institute for Global Health, Sydney, NSW, Australia
| | - Justin Presseau
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Michaël Chassé
- Department of Medicine, Université de Montréal, Montréal, Canada.,CHUM Research Center, Montréal, Canada
| | - Lauralyn McIntyre
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Canada.,Department of Medicine (Critical Care), The Ottawa Hospital, Ottawa, ON, Canada
| | - Dean Fergusson
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Canada
| | - Alexis F Turgeon
- Population Health and Optimal Health Practices Research Unit, CHU de Québec-Université Laval Research Center, Québec City, Québec, Canada.,Department of Anesthesiology & Critical Care, Université Laval, Québec City, Québec, Canada
| | - François Lauzier
- Population Health and Optimal Health Practices Research Unit, CHU de Québec-Université Laval Research Center, Québec City, Québec, Canada.,Department of Anesthesiology & Critical Care, Université Laval, Québec City, Québec, Canada.,Department of Medicine, Université Laval, Québec City, Québec, Canada
| | - Stephan A Mayer
- Departments of Neurology and Neurosurgery, Westchester Health Network, New York Medical College, Valhalla, NY, USA
| | - Shouri Lahiri
- Departments of Neurology, Neurosurgery, and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Tim Ramsay
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Shane English
- Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, Canada.,Department of Medicine (Critical Care), The Ottawa Hospital, Ottawa, ON, Canada
| |
Collapse
|
8
|
Dave C, Mei SHJ, McRae A, Hum C, Sullivan KJ, Champagne J, Ramsay T, McIntyre L. Comparison of freshly cultured versus cryopreserved mesenchymal stem cells in animal models of inflammation: A pre-clinical systematic review. eLife 2022; 11:75053. [PMID: 35838024 PMCID: PMC9286731 DOI: 10.7554/elife.75053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 06/05/2022] [Indexed: 12/09/2022] Open
Abstract
Background: Mesenchymal stem cells (MSCs) are multipotent cells that demonstrate therapeutic potential for the treatment of acute and chronic inflammatory-mediated conditions. Although controversial, some studies suggest that MSCs may lose their functionality with cryopreservation which could render them non-efficacious. Hence, we conducted a systematic review of comparative pre-clinical models of inflammation to determine if there are differences in in vivo measures of pre-clinical efficacy (primary outcomes) and in vitro potency (secondary outcomes) between freshly cultured and cryopreserved MSCs. Methods: A systematic search on OvidMEDLINE, EMBASE, BIOSIS, and Web of Science (until January 13, 2022) was conducted. The primary outcome included measures of in vivo pre-clinical efficacy; secondary outcomes included measures of in vitro MSC potency. Risk of bias was assessed by the SYRCLE ‘Risk of Bias’ assessment tool for pre-clinical studies. Results: Eighteen studies were included. A total of 257 in vivo pre-clinical efficacy experiments represented 101 distinct outcome measures. Of these outcomes, 2.3% (6/257) were significantly different at the 0.05 level or less; 2 favoured freshly cultured and 4 favoured cryopreserved MSCs. A total of 68 in vitro experiments represented 32 different potency measures; 13% (9/68) of the experiments were significantly different at the 0.05 level or less, with seven experiments favouring freshly cultured MSC and two favouring cryopreserved MSCs. Conclusions: The majority of preclinical primary in vivo efficacy and secondary in vitro potency outcomes were not significantly different (p<0.05) between freshly cultured and cryopreserved MSCs. Our systematic summary of the current evidence base may provide MSC basic and clinical research scientists additional rationale for considering a cryopreserved MSC product in their pre-clinical studies and clinical trials as well as help identify research gaps and guide future related research. Funding: Ontario Institute for Regenerative Medicine
Collapse
Affiliation(s)
- Chintan Dave
- Division of Critical Care Medicine, Department of Medicine, Western University, London, Canada
| | - Shirley H J Mei
- Regenerative Medicine Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Andrea McRae
- Regenerative Medicine Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Christine Hum
- Knowledge Synthesis Group, Ottawa Hospital Research Institute, Ottawa, Canada.,University of Ottawa, Ottawa, Canada
| | - Katrina J Sullivan
- Knowledge Synthesis Group, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Josee Champagne
- Knowledge Synthesis Group, Ottawa Hospital Research Institute, Ottawa, Canada.,Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Tim Ramsay
- Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Lauralyn McIntyre
- Knowledge Synthesis Group, Ottawa Hospital Research Institute, Ottawa, Canada.,Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Canada
| |
Collapse
|
9
|
Tan Y, Souza-Moreira L, Wang J, Salkhordeh M, Florian M, Wang Y, McIntyre L, Stewart D, Mei S. Mesenchymal Stem/Stromal Cells: CHARACTERIZATION OF THE SYSTEMIC IMMUNE LANDSCAPE IN SEPSIS REVEALS TIME-DEPENDENT MODULATION OF THE INNATE IMMUNE SYSTEM BY MSCS. Cytotherapy 2022. [DOI: 10.1016/s1465-3249(22)00187-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
10
|
Souza-Moreira L, Tan Y, Wang Y, Wang JP, Salkhordeh M, Virgo J, Florian M, Murray AB, Watpool I, McIntyre L, English S, Stewart DJ, Mei SH. Poly(I:C) Enhances Mesenchymal Stem Cell Control of Myeloid Cells From COVID-19 Patients. iScience 2022; 25:104188. [PMID: 35402859 PMCID: PMC8975597 DOI: 10.1016/j.isci.2022.104188] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 02/25/2022] [Accepted: 03/30/2022] [Indexed: 01/08/2023] Open
Abstract
Mesenchymal stem cells (MSCs) are being studied for the treatment of COVID-19-associated critical illness, due to their immunomodulatory properties. Here, we hypothesized that viral mimic-priming improves MSCs’ abilities to rebalance the dysregulated immune responses in COVID-19. Transcriptome analysis of poly(I:C)-primed MSCs (pIC-MSCs) showed upregulation of pathways in antiviral and immunomodulatory responses. Together with increased expression of antiviral proteins such as MX1, IFITM3, and OAS1, these changes translated to greater effector functions in regulating monocytes and granulocytes while further enhancing MSCs’ ability to block SARS-CoV-2 pseudovirus entry into epithelial cells. Most importantly, the addition of pIC-MSCs to COVID-19 patient whole blood significantly reduced inflammatory neutrophils and increased M2 monocytes while enhancing their phagocytic effector function. We reveal for the first time that MSCs can be primed by Toll-like receptor 3 agonist to improve their ability to rebalance the dysregulated immune responses seen in severe SARS-CoV-2 infection. Viral stimuli mimic enhances MSC’s antiviral and immunomodulatory molecular profile pIC-primed MSCs inhibit SARS-CoV2 pseudovirus entry into epithelial cells pIC-MSCs recalibrate dysregulated cellular response in COVID patient’s whole blood
Collapse
|
11
|
Chassé M, Neves Briard J, Yu M, P Carvalho L, W English S, D'Aragon F, Lauzier F, F Turgeon A, Dhanani S, McIntyre L, D Shemie S, Knoll G, Fergusson DA, Anthony SJ, Weiss MJ. Clinical evaluation and ancillary testing for the diagnosis of death by neurologic criteria: a cross-sectional survey of Canadian intensivists. Can J Anaesth 2022; 69:353-363. [PMID: 34931292 DOI: 10.1007/s12630-021-02166-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 10/06/2021] [Accepted: 10/14/2021] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Trust in the deceased organ donation process relies on the expectation that the diagnosis of death by neurologic criteria (DNC) is accurate and reliable. The objective of this study was to assess the perceptions and approaches to DNC diagnosis among Canadian intensivists. METHODS We conducted a self-administered, online, cross-sectional survey of Canadian intensivists. Our sampling frame included all intensivists practicing in Canadian institutions. Results are reported using descriptive statistics. RESULTS Among 550 identified intensivists, 249 (45%) completed the survey. Respondents indicated they would be comfortable diagnosing DNC based on clinical criteria alone in cases where there is movement in response to stimulation (119/248; 48%); inability to evaluate upper/lower extremity responses (84/249; 34%); spontaneous peripheral movement (76/249; 31%); inability to evaluate both oculocephalic and oculo-caloric reflexes (40/249; 16%); presence of high cervical spinal cord injury (40/249; 16%); and within 24 hr of hypoxemic-ischemic brain injury (38/247; 15%). Most respondents agreed that an ancillary test should always be conducted when a complete clinical evaluation is impossible (225/241; 93%); when there is possibility of a residual sedative effect (216/242; 89%); when the mechanism for brain injury is unclear (172/241; 71%); and if isolated brainstem injury is suspected (142/242; 59%). Sixty-six percent (158/241) believed that ancillary tests are sensitive and 55% (132/241) that they are specific for DNC. Respondents considered the following ancillary tests useful for DNC: four-vessel conventional angiography (211/241; 88%), nuclear imaging (179/240; 75%), computed tomography (CT) angiography (156/240; 65%), and CT perfusion (134/240; 56%). CONCLUSION There is variability in perceptions and approaches to DNC diagnosis among Canadian intensivists, and some practices are inconsistent with national recommendations.
Collapse
Affiliation(s)
- Michaël Chassé
- Centre de recherche du Centre hospitalier de l'Université de Montréal, 900 rue St-Denis, Montreal, QC, H2X 3H8, Canada.
- Medicine, Université de Montréal, Montreal, QC, Canada.
| | - Joel Neves Briard
- Centre de recherche du Centre hospitalier de l'Université de Montréal, 900 rue St-Denis, Montreal, QC, H2X 3H8, Canada
- Neuroscience, Université de Montréal, Montreal, QC, Canada
| | - Michael Yu
- Centre de recherche du Centre hospitalier de l'Université de Montréal, 900 rue St-Denis, Montreal, QC, H2X 3H8, Canada
| | - Livia P Carvalho
- Centre de recherche du Centre hospitalier de l'Université de Montréal, 900 rue St-Denis, Montreal, QC, H2X 3H8, Canada
| | - Shane W English
- Critical Care, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Frédérick D'Aragon
- Canadian Donation and Transplant Research Program, Ottawa, ON, Canada
- Anesthesiology, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - François Lauzier
- CHU de Québec Research Center, Université Laval, Quebec City, QC, Canada
- Critical Care, Université Laval, Quebec City, QC, Canada
| | - Alexis F Turgeon
- CHU de Québec Research Center, Université Laval, Quebec City, QC, Canada
- Critical Care, Université Laval, Quebec City, QC, Canada
| | - Sonny Dhanani
- Canadian Donation and Transplant Research Program, Ottawa, ON, Canada
- Critical Care, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Lauralyn McIntyre
- Critical Care, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Sam D Shemie
- Donation and Transplantation, Canadian Blood Services, Ottawa, ON, Canada
- Critical Care, Montreal Children's Hospital, Montreal, QC, Canada
- McGill University Health Centre and Research Institute, Montreal, QC, Canada
| | - Gregory Knoll
- Canadian Donation and Transplant Research Program, Ottawa, ON, Canada
- Critical Care, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Dean A Fergusson
- Critical Care, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Samantha J Anthony
- Canadian Donation and Transplant Research Program, Ottawa, ON, Canada
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - Matthew J Weiss
- Canadian Donation and Transplant Research Program, Ottawa, ON, Canada
- CHU de Québec Research Center, Université Laval, Quebec City, QC, Canada
- Donation and Transplantation, Canadian Blood Services, Ottawa, ON, Canada
- Transplant Québec, Montreal, QC, Canada
| |
Collapse
|
12
|
Lehr AR, Rached-d'Astous S, Barrowman N, Tsampalieros A, Parker M, McIntyre L, Sampson M, Menon K. Balanced Versus Unbalanced Fluid in Critically Ill Children: Systematic Review and Meta-Analysis. Pediatr Crit Care Med 2022; 23:181-191. [PMID: 34991134 PMCID: PMC8887852 DOI: 10.1097/pcc.0000000000002890] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The ideal crystalloid fluid bolus therapy for fluid resuscitation in children remains unclear, but pediatric data are limited. Administration of 0.9% saline has been associated with hyperchloremic metabolic acidosis and acute kidney injury. The primary objective of this systematic review was to compare the effect of balanced versus unbalanced fluid bolus therapy on the mean change in serum bicarbonate or pH within 24 hours in critically ill children. DATA SOURCES We searched MEDLINE including Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Embase, CENTRAL Trials Registry of the Cochrane Collaboration, ClinicalTrials.gov, and World Health Organization International Clinical Trials Registry Platform. STUDY SELECTION Using the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols guidelines, we retrieved all controlled trials and observational cohort studies comparing balanced and unbalanced resuscitative fluids in critically ill children. The primary outcome was the change in serum bicarbonate or blood pH. Secondary outcomes included the prevalence of hyperchloremia, acute kidney injury, renal replacement therapy, and mortality. DATA EXTRACTION Study screening, inclusion, data extraction, and risk of bias assessments were performed independently by two authors. DATA SYNTHESIS Among 481 references identified, 13 met inclusion criteria. In the meta-analysis of three randomized controlled trials with a population of 162 patients, we found a greater mean change in serum bicarbonate level (pooled estimate 1.60 mmol/L; 95% CI, 0.04-3.16; p = 0.04) and pH level (pooled mean difference 0.03; 95% CI, 0.00-0.06; p = 0.03) after 4-12 hours of rehydration with balanced versus unbalanced fluids. No differences were found in chloride serum level, acute kidney injury, renal replacement therapy, or mortality. CONCLUSIONS Our systematic review found some evidence of improvement in blood pH and bicarbonate values in critically ill children after 4-12 hours of fluid bolus therapy with balanced fluid compared with the unbalanced fluid. However, a randomized controlled trial is needed to establish whether these findings have an impact on clinical outcomes before recommendations can be generated.
Collapse
Affiliation(s)
- Anab Rebecca Lehr
- Division of Critical Care, Department of Pediatrics, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Soha Rached-d'Astous
- Division of Emergency Medicine, Department of Pediatrics, University of Montreal, CHU Sainte Justine, Montreal, QC, Canada
| | - Nick Barrowman
- Clinical Research Unit, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Anne Tsampalieros
- Clinical Research Unit, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Melissa Parker
- Division of Emergency Medicine, Department of Pediatrics, University of Toronto, Hospital for Sick Children, Toronto, ON, Canada
- Division of Critical Care, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Lauralyn McIntyre
- Division of Critical Care, Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Margaret Sampson
- Library Services, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Kusum Menon
- Division of Critical Care, Department of Pediatrics, University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| |
Collapse
|
13
|
Clark EG, McIntyre L, Watpool I, Kong JWY, Ramsay T, Sabri E, Canney M, Hundemer GL, Brown PA, Sood MM, Hiremath S. Intravenous albumin for the prevention of hemodynamic instability during sustained low-efficiency dialysis: a randomized controlled feasibility trial (The SAFER-SLED Study). Ann Intensive Care 2021; 11:174. [PMID: 34902089 PMCID: PMC8669086 DOI: 10.1186/s13613-021-00962-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 11/30/2021] [Indexed: 01/05/2023] Open
Abstract
Background Hemodynamic instability is a frequent complication of sustained low-efficiency dialysis (SLED) treatments in the ICU. Intravenous hyperoncotic albumin may prevent hypotension and facilitate ultrafiltration. In this feasibility trial, we sought to determine if a future trial, powered to evaluate clinically relevant outcomes, is feasible. Methods This single-center, blinded, placebo-controlled, randomized feasibility trial included patients with acute kidney injury who started SLED in the ICU. Patients were randomized to receive 25% albumin versus 0.9% saline (control) as 100 mL boluses at the start and midway through SLED, for up to 10 sessions. The recruitment rate and other feasibility outcomes were determined. Secondary exploratory outcomes included ultrafiltration volumes and metrics of hemodynamic instability. Results Sixty patients (271 SLED sessions) were recruited over 10 months. Age and severity of illness were similar between study groups. Most had septic shock and required vasopressor support at baseline. Protocol adherence occurred for 244 sessions (90%); no patients were lost to follow-up; no study-related adverse events were observed; open label albumin use was 9% and 15% in the albumin and saline arms, respectively. Ultrafiltration volumes were not significantly different. Compared to the saline group, the albumin group experienced less hemodynamic instability across all definitions assessed including a smaller absolute decrease in systolic blood pressure (mean difference 10.0 mmHg, 95% confidence interval 5.2–14.8); however, there were significant baseline differences in the groups with respect to vasopressor use prior to SLED sessions (80% vs 61% for albumin and saline groups, respectively). Conclusions The efficacy of using hyperoncotic albumin to prevent hemodynamic instability in critically ill patients receiving SLED remains unclear. A larger trial to evaluate its impact in this setting, including evaluating clinically relevant outcomes, is feasible. Trial registration ClinicalTrials.gov (NCT03665311); First Posted: Sept 11th, 2018. https://clinicaltrials.gov/ct2/show/NCT03665311?term=NCT03665311&draw=2&rank=1 Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00962-x.
Collapse
Affiliation(s)
- Edward G Clark
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada. .,Ottawa Hospital Research Institute, Ottawa, ON, Canada. .,The Ottawa Hospital-Riverside Campus, 1967 Riverside Drive, Ottawa, ON, K1H 7W9, Canada.
| | - Lauralyn McIntyre
- Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Irene Watpool
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Tim Ramsay
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Elham Sabri
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Mark Canney
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Gregory L Hundemer
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Pierre-Antoine Brown
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Manish M Sood
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Swapnil Hiremath
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| |
Collapse
|
14
|
Hickey M, McIntyre L, Taljaard M, Abdulaziz K, Yadav K, Hickey C, Perry JJ. Effect of prenotification on the response rate of a postal survey of emergency physicians: a randomised, controlled, assessor-blind trial. BMJ Open 2021; 11:e052843. [PMID: 34556517 PMCID: PMC8461690 DOI: 10.1136/bmjopen-2021-052843] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Response rates to physician surveys are typically low. The objective of this study was to determine the effect of a prenotification letter on the response rate of a postal survey of emergency physicians. DESIGN This was a substudy of a national, cross-sectional postal survey sent to emergency physicians in Canada. We randomised participants to either receive a postal prenotification letter prior to the survey, or to no prenotification letter. PARTICIPANTS A random sample of 500 emergency physicians in Canada. Participants were selected from the Canadian Medical Directory, a national medical directory which lists more than 99% of practising physicians in Canada. INTERVENTIONS Using computer-generated randomisation, physicians were randomised in a concealed fashion to receive a prenotification letter approximately 1 week prior to the survey, or to not receive a prenotification letter. All physicians received an unconditional incentive of a $3 coffee card with the survey instrument. In both groups, non-respondents were sent reminder surveys approximately every 14 days and a special contact using Xpresspost during the final contact attempt. OUTCOME The primary outcome was the survey response rate. RESULTS 201 of 447 eligible physicians returned the survey (45.0%). Of 231 eligible physicians contacted in the prenotification group, 80 (34.6%) returned the survey and among 237 eligible physicians contacted in the no-prenotification group, 121 (51.1%) returned the survey (absolute difference in proportions 16.5%, 95% CI 2.5 to 30.5, p=0.01). CONCLUSION Inclusion of a prenotification letter resulted in a lower response rate in this postal survey of emergency physicians. Given the added costs, time and effort required to send a prenotification letter, this study suggests that it may be more effective to omit the prenotification letter in physician postal surveys.
Collapse
Affiliation(s)
- Michael Hickey
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Lauralyn McIntyre
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Kasim Abdulaziz
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Krishan Yadav
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Carly Hickey
- Intensive Care Unit, Queensway Carleton Hospital, Ottawa, Ontario, Canada
| | - Jeffrey J Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| |
Collapse
|
15
|
Johnstone J, Meade M, Lauzier F, Marshall J, Duan E, Dionne J, Arabi YM, Heels-Ansdell D, Thabane L, Lamarche D, Surette M, Zytaruk N, Mehta S, Dodek P, McIntyre L, English S, Rochwerg B, Karachi T, Henderson W, Wood G, Ovakim D, Herridge M, Granton J, Wilcox ME, Goffi A, Stelfox HT, Niven D, Muscedere J, Lamontagne F, D’Aragon F, St.-Arnaud C, Ball I, Nagpal D, Girard M, Aslanian P, Charbonney E, Williamson D, Sligl W, Friedrich J, Adhikari NK, Marquis F, Archambault P, Khwaja K, Kristof A, Kutsogiannis J, Zarychanski R, Paunovic B, Reeve B, Lellouche F, Hosek P, Tsang J, Binnie A, Trop S, Loubani O, Hall R, Cirone R, Reynolds S, Lysecki P, Golan E, Cartin-Ceba R, Taylor R, Cook D. Effect of Probiotics on Incident Ventilator-Associated Pneumonia in Critically Ill Patients: A Randomized Clinical Trial. JAMA 2021; 326:1024-1033. [PMID: 34546300 PMCID: PMC8456390 DOI: 10.1001/jama.2021.13355] [Citation(s) in RCA: 80] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
IMPORTANCE Growing interest in microbial dysbiosis during critical illness has raised questions about the therapeutic potential of microbiome modification with probiotics. Prior randomized trials in this population suggest that probiotics reduce infection, particularly ventilator-associated pneumonia (VAP), although probiotic-associated infections have also been reported. OBJECTIVE To evaluate the effect of Lactobacillus rhamnosus GG on preventing VAP, additional infections, and other clinically important outcomes in the intensive care unit (ICU). DESIGN, SETTING, AND PARTICIPANTS Randomized placebo-controlled trial in 44 ICUs in Canada, the United States, and Saudi Arabia enrolling adults predicted to require mechanical ventilation for at least 72 hours. A total of 2653 patients were enrolled from October 2013 to March 2019 (final follow-up, October 2020). INTERVENTIONS Enteral L rhamnosus GG (1 × 1010 colony-forming units) (n = 1321) or placebo (n = 1332) twice daily in the ICU. MAIN OUTCOMES AND MEASURES The primary outcome was VAP determined by duplicate blinded central adjudication. Secondary outcomes were other ICU-acquired infections including Clostridioides difficile infection, diarrhea, antimicrobial use, ICU and hospital length of stay, and mortality. RESULTS Among 2653 randomized patients (mean age, 59.8 years [SD], 16.5 years), 2650 (99.9%) completed the trial (mean age, 59.8 years [SD], 16.5 years; 1063 women [40.1%.] with a mean Acute Physiology and Chronic Health Evaluation II score of 22.0 (SD, 7.8) and received the study product for a median of 9 days (IQR, 5-15 days). VAP developed among 289 of 1318 patients (21.9%) receiving probiotics vs 284 of 1332 controls (21.3%; hazard ratio [HR], 1.03 (95% CI, 0.87-1.22; P = .73, absolute difference, 0.6%, 95% CI, -2.5% to 3.7%). None of the 20 prespecified secondary outcomes, including other ICU-acquired infections, diarrhea, antimicrobial use, mortality, or length of stay showed a significant difference. Fifteen patients (1.1%) receiving probiotics vs 1 (0.1%) in the control group experienced the adverse event of L rhamnosus in a sterile site or the sole or predominant organism in a nonsterile site (odds ratio, 14.02; 95% CI, 1.79-109.58; P < .001). CONCLUSIONS AND RELEVANCE Among critically ill patients requiring mechanical ventilation, administration of the probiotic L rhamnosus GG compared with placebo, resulted in no significant difference in the development of ventilator-associated pneumonia. These findings do not support the use of L rhamnosus GG in critically ill patients. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02462590.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Yaseen M. Arabi
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | | | | | | | | | | | | | - Peter Dodek
- University of British Columbia, Vancouver, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Ian Ball
- Western University, London, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
16
|
Foster M, Presseau J, Podolsky E, McIntyre L, Papoulias M, Brehaut JC. How well do critical care audit and feedback interventions adhere to best practice? Development and application of the REFLECT-52 evaluation tool. Implement Sci 2021; 16:81. [PMID: 34404449 PMCID: PMC8369748 DOI: 10.1186/s13012-021-01145-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 07/24/2021] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Healthcare Audit and Feedback (A&F) interventions have been shown to be an effective means of changing healthcare professional behavior, but work is required to optimize them, as evidence suggests that A&F interventions are not improving over time. Recent published guidance has suggested an initial set of best practices that may help to increase intervention effectiveness, which focus on the "Nature of the desired action," "Nature of the data available for feedback," "Feedback display," and "Delivering the feedback intervention." We aimed to develop a generalizable evaluation tool that can be used to assess whether A&F interventions conform to these suggestions for best practice and conducted initial testing of the tool through application to a sample of critical care A&F interventions. METHODS We used a consensus-based approach to develop an evaluation tool from published guidance and subsequently applied the tool to conduct a secondary analysis of A&F interventions. To start, the 15 suggestions for improved feedback interventions published by Brehaut et al. were deconstructed into rateable items. Items were developed through iterative consensus meetings among researchers. These items were then piloted on 12 A&F studies (two reviewers met for consensus each time after independently applying the tool to four A&F intervention studies). After each consensus meeting, items were modified to improve clarity and specificity, and to help increase the reliability between coders. We then assessed the conformity to best practices of 17 critical care A&F interventions, sourced from a systematic review of A&F interventions on provider ordering of laboratory tests and transfusions in the critical care setting. Data for each criteria item was extracted by one coder and confirmed by a second; results were then aggregated and presented graphically or in a table and described narratively. RESULTS In total, 52 criteria items were developed (38 ratable items and 14 descriptive items). Eight studies targeted lab test ordering behaviors, and 10 studies targeted blood transfusion ordering. Items focused on specifying the "Nature of the Desired Action" were adhered to most commonly-feedback was often presented in the context of an external priority (13/17), showed or described a discrepancy in performance (14/17), and in all cases it was reasonable for the recipients to be responsible for the change in behavior (17/17). Items focused on the "Nature of the Data Available for Feedback" were adhered to less often-only some interventions provided individual (5/17) or patient-level data (5/17), and few included aspirational comparators (2/17), or justifications for specificity of feedback (4/17), choice of comparator (0/9) or the interval between reports (3/13). Items focused on the "Nature of the Feedback Display" were reported poorly-just under half of interventions reported providing feedback in more than one way (8/17) and interventions rarely included pilot-testing of the feedback (1/17 unclear) or presentation of a visual display and summary message in close proximity of each other (1/13). Items focused on "Delivering the Feedback Intervention" were also poorly reported-feedback rarely reported use of barrier/enabler assessments (0/17), involved target members in the development of the feedback (0/17), or involved explicit design to be received and discussed in a social context (3/17); however, most interventions clearly indicated who was providing the feedback (11/17), involved a facilitator (8/12) or involved engaging in self-assessment around the target behavior prior to receipt of feedback (12/17). CONCLUSIONS Many of the theory-informed best practice items were not consistently applied in critical care and can suggest clear ways to improve interventions. Standardized reporting of detailed intervention descriptions and feedback templates may also help to further advance research in this field. The 52-item tool can serve as a basis for reliably assessing concordance with best practice guidance in existing A&F interventions trialed in other healthcare settings, and could be used to inform future A&F intervention development. TRIAL REGISTRATION Not applicable.
Collapse
Affiliation(s)
- Madison Foster
- School of Epidemiology and Public Health, University of Ottawa, 451 Smyth Road, Ottawa, ON, K1H 8M5, Canada.,Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON, K1H 8L6, Canada
| | - Justin Presseau
- School of Epidemiology and Public Health, University of Ottawa, 451 Smyth Road, Ottawa, ON, K1H 8M5, Canada.,Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON, K1H 8L6, Canada.,School of Psychology, University of Ottawa, 136 Jean-Jacques Lussier, Vanier Hall, Ottawa, ON, K1N 6N5, Canada
| | - Eyal Podolsky
- School of Epidemiology and Public Health, University of Ottawa, 451 Smyth Road, Ottawa, ON, K1H 8M5, Canada
| | - Lauralyn McIntyre
- School of Epidemiology and Public Health, University of Ottawa, 451 Smyth Road, Ottawa, ON, K1H 8M5, Canada.,Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON, K1H 8L6, Canada.,Department of Critical Care Medicine, The Ottawa Hospital, General Campus, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
| | - Maria Papoulias
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON, K1H 8L6, Canada
| | - Jamie C Brehaut
- School of Epidemiology and Public Health, University of Ottawa, 451 Smyth Road, Ottawa, ON, K1H 8M5, Canada. .,Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON, K1H 8L6, Canada.
| |
Collapse
|
17
|
McGinn R, Fergusson DA, Stewart DJ, Kristof AS, Barron CC, Thebaud B, McIntyre L, Stacey D, Liepmann M, Dodelet-Devillers A, Zhang H, Renlund R, Lilley E, Downey GP, Brown EG, Côté L, Dos Santos CC, Fox-Robichaud AE, Hussain SNA, Laffey JG, Liu M, MacNeil J, Orlando H, Qureshi ST, Turner PV, Winston BW, Lalu MM. Surrogate Humane Endpoints in Small Animal Models of Acute Lung Injury: A Modified Delphi Consensus Study of Researchers and Laboratory Animal Veterinarians. Crit Care Med 2021; 49:311-323. [PMID: 33332817 DOI: 10.1097/ccm.0000000000004734] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES In many jurisdictions, ethical concerns require surrogate humane endpoints to replace death in small animal models of acute lung injury. Heterogenous selection and reporting of surrogate endpoints render interpretation and generalizability of findings between studies difficult. We aimed to establish expert-guided consensus among preclinical scientists and laboratory animal veterinarians on selection and reporting of surrogate endpoints, monitoring of these models, and the use of analgesia. DESIGN A three-round consensus process, using modified Delphi methodology, with researchers who use small animal models of acute lung injury and laboratory animal veterinarians who provide care for these animals. Statements on the selection and reporting of surrogate endpoints, monitoring, and analgesia were generated through a systematic search of MEDLINE and Embase. Participants were asked to suggest any additional potential statements for evaluation. SETTING A web-based survey of participants representing the two stakeholder groups (researchers, laboratory animal veterinarians). Statements were rated on level of evidence and strength of support by participants. A final face-to-face meeting was then held to discuss results. SUBJECTS None. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Forty-two statements were evaluated, and 29 were rated as important, with varying strength of evidence. The majority of evidence was based on rodent models of acute lung injury. Endpoints with strong support and evidence included temperature changes and body weight loss. Behavioral signs and respiratory distress also received support but were associated with lower levels of evidence. Participants strongly agreed that analgesia affects outcomes in these models and that none may be necessary following nonsurgical induction of acute lung injury. Finally, participants strongly supported transparent reporting of surrogate endpoints. A prototype composite score was also developed based on participant feedback. CONCLUSIONS We provide a preliminary framework that researchers and animal welfare committees may adapt for their needs. We have identified knowledge gaps that future research should address.
Collapse
Affiliation(s)
- Ryan McGinn
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Faculty of Medicine, University of Ottawa, ON, Canada
- Clinical Epidemiology Program, Blueprint Translational Research Group, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Blueprint Translational Research Group, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Duncan J Stewart
- Regenerative Medicine Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Arnold S Kristof
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Faculty of Medicine, University of Ottawa, ON, Canada
- Clinical Epidemiology Program, Blueprint Translational Research Group, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Regenerative Medicine Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, ON, Canada
- Meakins-Christie Laboratories, McGill University, Montreal, QC, Canada
- Department of Critical Care and Translational Research in Respiratory Diseases Program, McGill University Health Centre, Montreal, QC, Canada
- Division of Respirology, Departments of Critical Care and Medicine, McGill University, Montreal, QC, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
- Division of Critical Care, Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
- Faculty of Health Sciences, University of Ottawa, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- The Research Institute of the McGill University Health Center, McGill University, Montreal, QC, Canada
- Departments of Anesthesia, Medicine and Physiology, Keenan Research Centre for Biomedical Science, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Keenan Research Centre - Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Research Animals Department, Royal Society for the Prevention of Cruelty to Animals, Southwater, United Kingdom
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, CO
- Departments of Medicine and Immunology and Microbiology, University of Colorado, Denver, CO
- Neurosciences Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Biochemistry Microbiology and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Interdepartmental Division of Critical Care, and Keenan Research Center, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Animal & Veterinary Sciences, University of Ottawa, Ottawa, ON, Canada
- Department of Pathobiology, University of Guelph, Guelph, ON, Canada
- Departments of Critical Care Medicine, Medicine and Biochemistry and Molecular Biology, Cumming School and Medicine and the University of Calgary, Calgary, AB, Canada
| | - Carly C Barron
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Bernard Thebaud
- Regenerative Medicine Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, ON, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Lauralyn McIntyre
- Division of Critical Care, Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Dawn Stacey
- Faculty of Health Sciences, University of Ottawa, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Mark Liepmann
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Faculty of Medicine, University of Ottawa, ON, Canada
| | - Aurore Dodelet-Devillers
- The Research Institute of the McGill University Health Center, McGill University, Montreal, QC, Canada
| | - Haibo Zhang
- Departments of Anesthesia, Medicine and Physiology, Keenan Research Centre for Biomedical Science, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Richard Renlund
- Keenan Research Centre - Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Elliot Lilley
- Research Animals Department, Royal Society for the Prevention of Cruelty to Animals, Southwater, United Kingdom
| | - Gregory P Downey
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, CO
- Departments of Medicine and Immunology and Microbiology, University of Colorado, Denver, CO
| | - Earl G Brown
- Neurosciences Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Biochemistry Microbiology and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Lucie Côté
- The Research Institute of the McGill University Health Center, McGill University, Montreal, QC, Canada
| | - Claudia C Dos Santos
- Interdepartmental Division of Critical Care, and Keenan Research Center, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Alison E Fox-Robichaud
- Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
| | - Sabah N A Hussain
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Faculty of Medicine, University of Ottawa, ON, Canada
- Clinical Epidemiology Program, Blueprint Translational Research Group, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Regenerative Medicine Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, ON, Canada
- Meakins-Christie Laboratories, McGill University, Montreal, QC, Canada
- Department of Critical Care and Translational Research in Respiratory Diseases Program, McGill University Health Centre, Montreal, QC, Canada
- Division of Respirology, Departments of Critical Care and Medicine, McGill University, Montreal, QC, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
- Division of Critical Care, Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
- Faculty of Health Sciences, University of Ottawa, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- The Research Institute of the McGill University Health Center, McGill University, Montreal, QC, Canada
- Departments of Anesthesia, Medicine and Physiology, Keenan Research Centre for Biomedical Science, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Keenan Research Centre - Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Research Animals Department, Royal Society for the Prevention of Cruelty to Animals, Southwater, United Kingdom
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, CO
- Departments of Medicine and Immunology and Microbiology, University of Colorado, Denver, CO
- Neurosciences Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Biochemistry Microbiology and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Interdepartmental Division of Critical Care, and Keenan Research Center, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Animal & Veterinary Sciences, University of Ottawa, Ottawa, ON, Canada
- Department of Pathobiology, University of Guelph, Guelph, ON, Canada
- Departments of Critical Care Medicine, Medicine and Biochemistry and Molecular Biology, Cumming School and Medicine and the University of Calgary, Calgary, AB, Canada
| | - John G Laffey
- Departments of Anesthesia, Medicine and Physiology, Keenan Research Centre for Biomedical Science, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Mingyao Liu
- Departments of Anesthesia, Medicine and Physiology, Keenan Research Centre for Biomedical Science, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Jenna MacNeil
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Holly Orlando
- Animal & Veterinary Sciences, University of Ottawa, Ottawa, ON, Canada
| | - Salman T Qureshi
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Faculty of Medicine, University of Ottawa, ON, Canada
- Clinical Epidemiology Program, Blueprint Translational Research Group, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Regenerative Medicine Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, ON, Canada
- Meakins-Christie Laboratories, McGill University, Montreal, QC, Canada
- Department of Critical Care and Translational Research in Respiratory Diseases Program, McGill University Health Centre, Montreal, QC, Canada
- Division of Respirology, Departments of Critical Care and Medicine, McGill University, Montreal, QC, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
- Division of Critical Care, Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
- Faculty of Health Sciences, University of Ottawa, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- The Research Institute of the McGill University Health Center, McGill University, Montreal, QC, Canada
- Departments of Anesthesia, Medicine and Physiology, Keenan Research Centre for Biomedical Science, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Keenan Research Centre - Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Research Animals Department, Royal Society for the Prevention of Cruelty to Animals, Southwater, United Kingdom
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, CO
- Departments of Medicine and Immunology and Microbiology, University of Colorado, Denver, CO
- Neurosciences Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Biochemistry Microbiology and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Interdepartmental Division of Critical Care, and Keenan Research Center, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Animal & Veterinary Sciences, University of Ottawa, Ottawa, ON, Canada
- Department of Pathobiology, University of Guelph, Guelph, ON, Canada
- Departments of Critical Care Medicine, Medicine and Biochemistry and Molecular Biology, Cumming School and Medicine and the University of Calgary, Calgary, AB, Canada
| | - Patricia V Turner
- Department of Pathobiology, University of Guelph, Guelph, ON, Canada
| | - Brent W Winston
- Departments of Critical Care Medicine, Medicine and Biochemistry and Molecular Biology, Cumming School and Medicine and the University of Calgary, Calgary, AB, Canada
| | - Manoj M Lalu
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Faculty of Medicine, University of Ottawa, ON, Canada
- Clinical Epidemiology Program, Blueprint Translational Research Group, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Regenerative Medicine Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, ON, Canada
- Meakins-Christie Laboratories, McGill University, Montreal, QC, Canada
- Department of Critical Care and Translational Research in Respiratory Diseases Program, McGill University Health Centre, Montreal, QC, Canada
- Division of Respirology, Departments of Critical Care and Medicine, McGill University, Montreal, QC, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
- Division of Critical Care, Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
- Faculty of Health Sciences, University of Ottawa, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- The Research Institute of the McGill University Health Center, McGill University, Montreal, QC, Canada
- Departments of Anesthesia, Medicine and Physiology, Keenan Research Centre for Biomedical Science, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Keenan Research Centre - Li Ka Shing Knowledge Institute, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Research Animals Department, Royal Society for the Prevention of Cruelty to Animals, Southwater, United Kingdom
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, CO
- Departments of Medicine and Immunology and Microbiology, University of Colorado, Denver, CO
- Neurosciences Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Biochemistry Microbiology and Immunology, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Interdepartmental Division of Critical Care, and Keenan Research Center, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Department of Medicine and Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
- Animal & Veterinary Sciences, University of Ottawa, Ottawa, ON, Canada
- Department of Pathobiology, University of Guelph, Guelph, ON, Canada
- Departments of Critical Care Medicine, Medicine and Biochemistry and Molecular Biology, Cumming School and Medicine and the University of Calgary, Calgary, AB, Canada
| |
Collapse
|
18
|
Affiliation(s)
- Edward G Clark
- Division of Nephrology, Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, ON, Canada.
| | - Swapnil Hiremath
- Division of Nephrology, Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, ON, Canada
| | - Lauralyn McIntyre
- Division of Critical Care, Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, ON, Canada
| | - Ron Wald
- Division of Nephrology, St Michael's Hospital and Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Gregory L Hundemer
- Division of Nephrology, Department of Medicine, The Ottawa Hospital and University of Ottawa, Ottawa, ON, Canada
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria
| |
Collapse
|
19
|
Tarazan N, Alshehri M, Sharif S, Al Duhailib Z, Møller MH, Belley-Cote E, Alshahrani M, Centofanti J, McIntyre L, Baw B, Meade M, Alhazzani W. Neuromuscular blocking agents in acute respiratory distress syndrome: updated systematic review and meta-analysis of randomized trials. Intensive Care Med Exp 2020; 8:61. [PMID: 33095344 PMCID: PMC7582438 DOI: 10.1186/s40635-020-00348-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 09/29/2020] [Indexed: 12/18/2022] Open
Abstract
Purpose Existing clinical practice guidelines support the use of neuromuscular blocking agents (NMBA) in acute respiratory distress syndrome (ARDS); however, a recent large randomized clinical trial (RCT) has questioned this practice. Therefore, we updated a previous systematic review to determine the efficacy and safety of NMBAs in ARDS. Methods We searched MEDLINE, EMBASE (October 2012 to July 2019), the Cochrane (Central) database, and clinical trial registries (ClinicalTrials.gov, ISRCTN Register, and WHO ICTRP) for RCTs comparing the effects of NMBA as a continuous infusion versus placebo or no NMBA infusion (but allowing intermittent NMBA boluses) on patient-important outcomes for adults with ARDS. Two independent reviewers assessed the methodologic quality of the primary studies and abstracted data. Results Seven RCTs, including four new RCTs, met eligibility criteria for this review. These trials enrolled 1598 patients with moderate to severe ARDS at centers in the USA, France, and China. All trials assessed short-term continuous infusions of cisatracurium or vecuronium. The pooled estimate for mortality outcomes showed significant statistical heterogeneity, which was only explained by a subgroup analysis by depth of sedation in the control arm. A continuous NMBA infusion did not improve mortality when compared to a light sedation strategy with no NMBA infusion (relative risk [RR] 0.99; 95% CI 0.86–1.15; moderate certainty; P = 0.93). On the other hand, continuous NMBA infusion reduced mortality when compared to deep sedation with as needed NMBA boluses (RR 0.71; 95% CI 0.57–0.89; low certainty; P = 0.003). Continuous NMBA infusion reduced the rate of barotrauma (RR 0.55; 95% CI 0.35–0.85, moderate certainty; P = 0.008) across eligible trials, but the effect on ventilator-free days, duration of mechanical ventilation, and ICU-acquired weakness was uncertain. Conclusions Inconsistency in study methods and findings precluded the pooling of all trials for mortality. In a pre-planned sensitivity analysis, the impact of NMBA infusion on mortality depends on the strategy used in the control arm, showing reduced mortality when compared to deep sedation, but no effect on mortality when compared to lighter sedation. In both situations, a continuous NMBA infusion may reduce the risk of barotrauma, but the effects on other patient-important outcomes remain unclear. Future research, including an individual patient data meta-analysis, could help clarify some of the observed findings in this updated systematic review.
Collapse
Affiliation(s)
- Nehal Tarazan
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Moayad Alshehri
- Department of Medicine, McMaster University, Hamilton, Canada.,Department of Internal Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Sameer Sharif
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, Canada
| | - Zainab Al Duhailib
- Department of Medicine, McMaster University, Hamilton, Canada.,Department of Critical Care Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Morten Hylander Møller
- Department of Intensive Care 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - Mohammed Alshahrani
- Department of Emergency and Critical Care, Imam Abdulrahman Ben Faisal University, Dammam, Saudi Arabia
| | - John Centofanti
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Lauralyn McIntyre
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Bandar Baw
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Maureen Meade
- Department of Medicine, McMaster University, Hamilton, Canada.,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, L8S 4K1, Canada
| | - Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, Canada. .,Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, L8S 4K1, Canada.
| | | |
Collapse
|
20
|
McNally JD, O'Hearn K, Fergusson DA, Lougheed J, Doherty DR, Maharajh G, Weiler H, Jones G, Khamessan A, Redpath S, Geier P, McIntyre L, Lawson ML, Girolamo T, Menon K. Prevention of post-cardiac surgery vitamin D deficiency in children with congenital heart disease: a pilot feasibility dose evaluation randomized controlled trial. Pilot Feasibility Stud 2020; 6:159. [PMID: 33110622 PMCID: PMC7583219 DOI: 10.1186/s40814-020-00700-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 09/29/2020] [Indexed: 02/07/2023] Open
Abstract
Background The vast majority of children undergoing cardiac surgery have low vitamin D levels post-operative, which may contribute to greater illness severity and worse clinical outcomes. Prior to the initiation of a large phase III clinical trial focused on clinical outcomes, studies are required to evaluate the feasibility of the study protocol, including whether the proposed dosing regimen can safely prevent post-operative vitamin D deficiency in this high-risk population. Methods We conducted a two-arm, double-blind dose evaluation randomized controlled trial in children requiring cardiopulmonary bypass for congenital heart disease. Pre-operatively, participants were randomized to receive cholecalciferol representing usual care (< 1 year = 400 IU/day, > 1 year = 600 IU/day) or a higher dose approximating the Institute of Medicine tolerable upper intake level (< 1 year = 1600 IU/day, > 1 year = 2400 IU/day). The feasibility outcomes were post-operative vitamin D status (primary), vitamin D-related adverse events, accrual rate, study withdrawal rate, blinding, and protocol non-adherence. Results Forty-six children were randomized, and five withdrew prior to surgery, leaving 41 children (21 high dose, 20 usual care) in the final analysis. The high dose group had higher 25-hydroxyvitamin D concentrations both intraoperatively (mean difference + 25.9 nmol/L; 95% CI 8.3–43.5) and post-operatively (mean difference + 17.2 nmol/L; 95% CI 5.5–29.0). Fewer participants receiving high-dose supplementation had post-operative serum 25-hydroxyvitamin D concentrations under 50 nmol/L, compared with usual care (RR 0.31, 95% CI 0.11–0.87). Post-operative vitamin D status was associated with the treatment arm and the number of doses received. There were no cases of hypercalcemia, and no significant adverse events related to vitamin D. While only 75% of the target sample size was recruited (limited funding), the consent rate (83%), accrual rate (1.5 per site month), number of withdrawals (11%), and ability to maintain blinding support feasibility of a larger trial. Conclusions Pre-operative daily high-dose supplementation improved vitamin D status pre-operatively and at time of pediatric ICU admission. The protocol for a more definitive trial should limit enrollment of children with at least 30 days between randomization and surgery to allow adequate duration of supplementation or consider a loading dose. Trial registration ClinicalTrials.gov, NCT01838447. Registered on April 24, 2013
Collapse
Affiliation(s)
- James Dayre McNally
- Department of Pediatrics, Division of Critical Care, University of Ottawa, Ottawa, Canada.,CHEO, 401 Smyth Road, Ottawa, ON K1H 8L1 Canada
| | - Katie O'Hearn
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Dean A Fergusson
- Department of Medicine, University of Ottawa, Ottawa, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Jane Lougheed
- Department of Pediatrics, Division of Cardiology, University of Ottawa, Ottawa, Canada
| | | | - Gyaandeo Maharajh
- Department of Pediatric Surgery, Division of Cardiovascular Surgery, University of Ottawa, Ottawa, Canada
| | - Hope Weiler
- School of Human Nutrition, Faculty of Agricultural and Environmental Sciences, McGill University, Montreal, Canada
| | - Glenville Jones
- School of Medicine, Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Canada
| | - Ali Khamessan
- Euro-Pharm International Canada Inc., Montreal, Canada
| | - Stephanie Redpath
- Department of Pediatrics, Division of Neonatology, University of Ottawa, Ottawa, Canada
| | - Pavel Geier
- Department of Pediatrics, Division of Nephrology, University of Ottawa, Ottawa, Canada
| | - Lauralyn McIntyre
- Department of Medicine (Division of Critical Care), Ottawa Hospital Research Institute (OHRI), University of Ottawa, Ottawa, Canada
| | - Margaret L Lawson
- Department of Pediatrics, Division of Endocrinology, University of Ottawa, Ottawa, Canada
| | - Tara Girolamo
- Department of Pediatric Surgery, Division of Cardiovascular Surgery, University of Ottawa, Ottawa, Canada
| | - Kusum Menon
- Department of Pediatrics, Division of Critical Care, University of Ottawa, Ottawa, Canada
| | | |
Collapse
|
21
|
Angus DC, Derde L, Al-Beidh F, Annane D, Arabi Y, Beane A, van Bentum-Puijk W, Berry L, Bhimani Z, Bonten M, Bradbury C, Brunkhorst F, Buxton M, Buzgau A, Cheng AC, de Jong M, Detry M, Estcourt L, Fitzgerald M, Goossens H, Green C, Haniffa R, Higgins AM, Horvat C, Hullegie SJ, Kruger P, Lamontagne F, Lawler PR, Linstrum K, Litton E, Lorenzi E, Marshall J, McAuley D, McGlothin A, McGuinness S, McVerry B, Montgomery S, Mouncey P, Murthy S, Nichol A, Parke R, Parker J, Rowan K, Sanil A, Santos M, Saunders C, Seymour C, Turner A, van de Veerdonk F, Venkatesh B, Zarychanski R, Berry S, Lewis RJ, McArthur C, Webb SA, Gordon AC, Al-Beidh F, Angus D, Annane D, Arabi Y, van Bentum-Puijk W, Berry S, Beane A, Bhimani Z, Bonten M, Bradbury C, Brunkhorst F, Buxton M, Cheng A, De Jong M, Derde L, Estcourt L, Goossens H, Gordon A, Green C, Haniffa R, Lamontagne F, Lawler P, Litton E, Marshall J, McArthur C, McAuley D, McGuinness S, McVerry B, Montgomery S, Mouncey P, Murthy S, Nichol A, Parke R, Rowan K, Seymour C, Turner A, van de Veerdonk F, Webb S, Zarychanski R, Campbell L, Forbes A, Gattas D, Heritier S, Higgins L, Kruger P, Peake S, Presneill J, Seppelt I, Trapani T, Young P, Bagshaw S, Daneman N, Ferguson N, Misak C, Santos M, Hullegie S, Pletz M, Rohde G, Rowan K, Alexander B, Basile K, Girard T, Horvat C, Huang D, Linstrum K, Vates J, Beasley R, Fowler R, McGloughlin S, Morpeth S, Paterson D, Venkatesh B, Uyeki T, Baillie K, Duffy E, Fowler R, Hills T, Orr K, Patanwala A, Tong S, Netea M, Bihari S, Carrier M, Fergusson D, Goligher E, Haidar G, Hunt B, Kumar A, Laffan M, Lawless P, Lother S, McCallum P, Middeldopr S, McQuilten Z, Neal M, Pasi J, Schutgens R, Stanworth S, Turgeon A, Weissman A, Adhikari N, Anstey M, Brant E, de Man A, Lamonagne F, Masse MH, Udy A, Arnold D, Begin P, Charlewood R, Chasse M, Coyne M, Cooper J, Daly J, Gosbell I, Harvala-Simmonds H, Hills T, MacLennan S, Menon D, McDyer J, Pridee N, Roberts D, Shankar-Hari M, Thomas H, Tinmouth A, Triulzi D, Walsh T, Wood E, Calfee C, O’Kane C, Shyamsundar M, Sinha P, Thompson T, Young I, Bihari S, Hodgson C, Laffey J, McAuley D, Orford N, Neto A, Detry M, Fitzgerald M, Lewis R, McGlothlin A, Sanil A, Saunders C, Berry L, Lorenzi E, Miller E, Singh V, Zammit C, van Bentum Puijk W, Bouwman W, Mangindaan Y, Parker L, Peters S, Rietveld I, Raymakers K, Ganpat R, Brillinger N, Markgraf R, Ainscough K, Brickell K, Anjum A, Lane JB, Richards-Belle A, Saull M, Wiley D, Bion J, Connor J, Gates S, Manax V, van der Poll T, Reynolds J, van Beurden M, Effelaar E, Schotsman J, Boyd C, Harland C, Shearer A, Wren J, Clermont G, Garrard W, Kalchthaler K, King A, Ricketts D, Malakoutis S, Marroquin O, Music E, Quinn K, Cate H, Pearson K, Collins J, Hanson J, Williams P, Jackson S, Asghar A, Dyas S, Sutu M, Murphy S, Williamson D, Mguni N, Potter A, Porter D, Goodwin J, Rook C, Harrison S, Williams H, Campbell H, Lomme K, Williamson J, Sheffield J, van’t Hoff W, McCracken P, Young M, Board J, Mart E, Knott C, Smith J, Boschert C, Affleck J, Ramanan M, D’Souza R, Pateman K, Shakih A, Cheung W, Kol M, Wong H, Shah A, Wagh A, Simpson J, Duke G, Chan P, Cartner B, Hunter S, Laver R, Shrestha T, Regli A, Pellicano A, McCullough J, Tallott M, Kumar N, Panwar R, Brinkerhoff G, Koppen C, Cazzola F, Brain M, Mineall S, Fischer R, Biradar V, Soar N, White H, Estensen K, Morrison L, Smith J, Cooper M, Health M, Shehabi Y, Al-Bassam W, Hulley A, Whitehead C, Lowrey J, Gresha R, Walsham J, Meyer J, Harward M, Venz E, Williams P, Kurenda C, Smith K, Smith M, Garcia R, Barge D, Byrne D, Byrne K, Driscoll A, Fortune L, Janin P, Yarad E, Hammond N, Bass F, Ashelford A, Waterson S, Wedd S, McNamara R, Buhr H, Coles J, Schweikert S, Wibrow B, Rauniyar R, Myers E, Fysh E, Dawda A, Mevavala B, Litton E, Ferrier J, Nair P, Buscher H, Reynolds C, Santamaria J, Barbazza L, Homes J, Smith R, Murray L, Brailsford J, Forbes L, Maguire T, Mariappa V, Smith J, Simpson S, Maiden M, Bone A, Horton M, Salerno T, Sterba M, Geng W, Depuydt P, De Waele J, De Bus L, Fierens J, Bracke S, Reeve B, Dechert W, Chassé M, Carrier FM, Boumahni D, Benettaib F, Ghamraoui A, Bellemare D, Cloutier È, Francoeur C, Lamontagne F, D’Aragon F, Carbonneau E, Leblond J, Vazquez-Grande G, Marten N, Wilson M, Albert M, Serri K, Cavayas A, Duplaix M, Williams V, Rochwerg B, Karachi T, Oczkowski S, Centofanti J, Millen T, Duan E, Tsang J, Patterson L, English S, Watpool I, Porteous R, Miezitis S, McIntyre L, Brochard L, Burns K, Sandhu G, Khalid I, Binnie A, Powell E, McMillan A, Luk T, Aref N, Andric Z, Cviljevic S, Đimoti R, Zapalac M, Mirković G, Baršić B, Kutleša M, Kotarski V, Vujaklija Brajković A, Babel J, Sever H, Dragija L, Kušan I, Vaara S, Pettilä L, Heinonen J, Kuitunen A, Karlsson S, Vahtera A, Kiiski H, Ristimäki S, Azaiz A, Charron C, Godement M, Geri G, Vieillard-Baron A, Pourcine F, Monchi M, Luis D, Mercier R, Sagnier A, Verrier N, Caplin C, Siami S, Aparicio C, Vautier S, Jeblaoui A, Fartoukh M, Courtin L, Labbe V, Leparco C, Muller G, Nay MA, Kamel T, Benzekri D, Jacquier S, Mercier E, Chartier D, Salmon C, Dequin P, Schneider F, Morel G, L’Hotellier S, Badie J, Berdaguer FD, Malfroy S, Mezher C, Bourgoin C, Megarbane B, Voicu S, Deye N, Malissin I, Sutterlin L, Guitton C, Darreau C, Landais M, Chudeau N, Robert A, Moine P, Heming N, Maxime V, Bossard I, Nicholier TB, Colin G, Zinzoni V, Maquigneau N, Finn A, Kreß G, Hoff U, Friedrich Hinrichs C, Nee J, Pletz M, Hagel S, Ankert J, Kolanos S, Bloos F, Petros S, Pasieka B, Kunz K, Appelt P, Schütze B, Kluge S, Nierhaus A, Jarczak D, Roedl K, Weismann D, Frey A, Klinikum Neukölln V, Reill L, Distler M, Maselli A, Bélteczki J, Magyar I, Fazekas Á, Kovács S, Szőke V, Szigligeti G, Leszkoven J, Collins D, Breen P, Frohlich S, Whelan R, McNicholas B, Scully M, Casey S, Kernan M, Doran P, O’Dywer M, Smyth M, Hayes L, Hoiting O, Peters M, Rengers E, Evers M, Prinssen A, Bosch Ziekenhuis J, Simons K, Rozendaal W, Polderman F, de Jager P, Moviat M, Paling A, Salet A, Rademaker E, Peters AL, de Jonge E, Wigbers J, Guilder E, Butler M, Cowdrey KA, Newby L, Chen Y, Simmonds C, McConnochie R, Ritzema Carter J, Henderson S, Van Der Heyden K, Mehrtens J, Williams T, Kazemi A, Song R, Lai V, Girijadevi D, Everitt R, Russell R, Hacking D, Buehner U, Williams E, Browne T, Grimwade K, Goodson J, Keet O, Callender O, Martynoga R, Trask K, Butler A, Schischka L, Young C, Lesona E, Olatunji S, Robertson Y, José N, Amaro dos Santos Catorze T, de Lima Pereira TNA, Neves Pessoa LM, Castro Ferreira RM, Pereira Sousa Bastos JM, Aysel Florescu S, Stanciu D, Zaharia MF, Kosa AG, Codreanu D, Marabi Y, Al Qasim E, Moneer Hagazy M, Al Swaidan L, Arishi H, Muñoz-Bermúdez R, Marin-Corral J, Salazar Degracia A, Parrilla Gómez F, Mateo López MI, Rodriguez Fernandez J, Cárcel Fernández S, Carmona Flores R, León López R, de la Fuente Martos C, Allan A, Polgarova P, Farahi N, McWilliam S, Hawcutt D, Rad L, O’Malley L, Whitbread J, Kelsall O, Wild L, Thrush J, Wood H, Austin K, Donnelly A, Kelly M, O’Kane S, McClintock D, Warnock M, Johnston P, Gallagher LJ, Mc Goldrick C, Mc Master M, Strzelecka A, Jha R, Kalogirou M, Ellis C, Krishnamurthy V, Deelchand V, Silversides J, McGuigan P, Ward K, O’Neill A, Finn S, Phillips B, Mullan D, Oritz-Ruiz de Gordoa L, Thomas M, Sweet K, Grimmer L, Johnson R, Pinnell J, Robinson M, Gledhill L, Wood T, Morgan M, Cole J, Hill H, Davies M, Antcliffe D, Templeton M, Rojo R, Coghlan P, Smee J, Mackay E, Cort J, Whileman A, Spencer T, Spittle N, Kasipandian V, Patel A, Allibone S, Genetu RM, Ramali M, Ghosh A, Bamford P, London E, Cawley K, Faulkner M, Jeffrey H, Smith T, Brewer C, Gregory J, Limb J, Cowton A, O’Brien J, Nikitas N, Wells C, Lankester L, Pulletz M, Williams P, Birch J, Wiseman S, Horton S, Alegria A, Turki S, Elsefi T, Crisp N, Allen L, McCullagh I, Robinson P, Hays C, Babio-Galan M, Stevenson H, Khare D, Pinder M, Selvamoni S, Gopinath A, Pugh R, Menzies D, Mackay C, Allan E, Davies G, Puxty K, McCue C, Cathcart S, Hickey N, Ireland J, Yusuff H, Isgro G, Brightling C, Bourne M, Craner M, Watters M, Prout R, Davies L, Pegler S, Kyeremeh L, Arbane G, Wilson K, Gomm L, Francia F, Brett S, Sousa Arias S, Elin Hall R, Budd J, Small C, Birch J, Collins E, Henning J, Bonner S, Hugill K, Cirstea E, Wilkinson D, Karlikowski M, Sutherland H, Wilhelmsen E, Woods J, North J, Sundaran D, Hollos L, Coburn S, Walsh J, Turns M, Hopkins P, Smith J, Noble H, Depante MT, Clarey E, Laha S, Verlander M, Williams A, Huckle A, Hall A, Cooke J, Gardiner-Hill C, Maloney C, Qureshi H, Flint N, Nicholson S, Southin S, Nicholson A, Borgatta B, Turner-Bone I, Reddy A, Wilding L, Chamara Warnapura L, Agno Sathianathan R, Golden D, Hart C, Jones J, Bannard-Smith J, Henry J, Birchall K, Pomeroy F, Quayle R, Makowski A, Misztal B, Ahmed I, KyereDiabour T, Naiker K, Stewart R, Mwaura E, Mew L, Wren L, Willams F, Innes R, Doble P, Hutter J, Shovelton C, Plumb B, Szakmany T, Hamlyn V, Hawkins N, Lewis S, Dell A, Gopal S, Ganguly S, Smallwood A, Harris N, Metherell S, Lazaro JM, Newman T, Fletcher S, Nortje J, Fottrell-Gould D, Randell G, Zaman M, Elmahi E, Jones A, Hall K, Mills G, Ryalls K, Bowler H, Sall J, Bourne R, Borrill Z, Duncan T, Lamb T, Shaw J, Fox C, Moreno Cuesta J, Xavier K, Purohit D, Elhassan M, Bakthavatsalam D, Rowland M, Hutton P, Bashyal A, Davidson N, Hird C, Chhablani M, Phalod G, Kirkby A, Archer S, Netherton K, Reschreiter H, Camsooksai J, Patch S, Jenkins S, Pogson D, Rose S, Daly Z, Brimfield L, Claridge H, Parekh D, Bergin C, Bates M, Dasgin J, McGhee C, Sim M, Hay SK, Henderson S, Phull MK, Zaidi A, Pogreban T, Rosaroso LP, Harvey D, Lowe B, Meredith M, Ryan L, Hormis A, Walker R, Collier D, Kimpton S, Oakley S, Rooney K, Rodden N, Hughes E, Thomson N, McGlynn D, Walden A, Jacques N, Coles H, Tilney E, Vowell E, Schuster-Bruce M, Pitts S, Miln R, Purandare L, Vamplew L, Spivey M, Bean S, Burt K, Moore L, Day C, Gibson C, Gordon E, Zitter L, Keenan S, Baker E, Cherian S, Cutler S, Roynon-Reed A, Harrington K, Raithatha A, Bauchmuller K, Ahmad N, Grecu I, Trodd D, Martin J, Wrey Brown C, Arias AM, Craven T, Hope D, Singleton J, Clark S, Rae N, Welters I, Hamilton DO, Williams K, Waugh V, Shaw D, Puthucheary Z, Martin T, Santos F, Uddin R, Somerville A, Tatham KC, Jhanji S, Black E, Dela Rosa A, Howle R, Tully R, Drummond A, Dearden J, Philbin J, Munt S, Vuylsteke A, Chan C, Victor S, Matsa R, Gellamucho M, Creagh-Brown B, Tooley J, Montague L, De Beaux F, Bullman L, Kersiake I, Demetriou C, Mitchard S, Ramos L, White K, Donnison P, Johns M, Casey R, Mattocks L, Salisbury S, Dark P, Claxton A, McLachlan D, Slevin K, Lee S, Hulme J, Joseph S, Kinney F, Senya HJ, Oborska A, Kayani A, Hadebe B, Orath Prabakaran R, Nichols L, Thomas M, Worner R, Faulkner B, Gendall E, Hayes K, Hamilton-Davies C, Chan C, Mfuko C, Abbass H, Mandadapu V, Leaver S, Forton D, Patel K, Paramasivam E, Powell M, Gould R, Wilby E, Howcroft C, Banach D, Fernández de Pinedo Artaraz Z, Cabreros L, White I, Croft M, Holland N, Pereira R, Zaki A, Johnson D, Jackson M, Garrard H, Juhaz V, Roy A, Rostron A, Woods L, Cornell S, Pillai S, Harford R, Rees T, Ivatt H, Sundara Raman A, Davey M, Lee K, Barber R, Chablani M, Brohi F, Jagannathan V, Clark M, Purvis S, Wetherill B, Dushianthan A, Cusack R, de Courcy-Golder K, Smith S, Jackson S, Attwood B, Parsons P, Page V, Zhao XB, Oza D, Rhodes J, Anderson T, Morris S, Xia Le Tai C, Thomas A, Keen A, Digby S, Cowley N, Wild L, Southern D, Reddy H, Campbell A, Watkins C, Smuts S, Touma O, Barnes N, Alexander P, Felton T, Ferguson S, Sellers K, Bradley-Potts J, Yates D, Birkinshaw I, Kell K, Marshall N, Carr-Knott L, Summers C. Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial. JAMA 2020. [PMID: 32876697 DOI: 10.1001/jama.2020.1702221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited. OBJECTIVE To determine whether hydrocortisone improves outcome for patients with severe COVID-19. DESIGN, SETTING, AND PARTICIPANTS An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020. INTERVENTIONS The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108). MAIN OUTCOMES AND MEASURES The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%). RESULTS After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively. CONCLUSIONS AND RELEVANCE Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02735707.
Collapse
Affiliation(s)
- Derek C Angus
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Lennie Derde
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- Intensive Care Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Farah Al-Beidh
- Division of Anaesthetics, Pain Medicine and Intensive Care Medicine, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Djillali Annane
- Intensive Care Unit, Raymond Poincaré Hospital (AP-HP), Paris, France
- Simone Veil School of Medicine, University of Versailles, Versailles, France
- University Paris Saclay, Garches, France
| | - Yaseen Arabi
- Intensive Care Department, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Abigail Beane
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Wilma van Bentum-Puijk
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Zahra Bhimani
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Marc Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Charlotte Bradbury
- Bristol Royal Informatory, Bristol, United Kingdom
- University of Bristol, Bristol, United Kingdom
| | - Frank Brunkhorst
- Center for Clinical Studies and Center for Sepsis Control and Care (CSCC), Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Meredith Buxton
- Global Coalition for Adaptive Research, San Francisco, California
| | - Adrian Buzgau
- Helix, Monash University, Melbourne, Victoria, Australia
| | - Allen C Cheng
- Infection Prevention and Healthcare Epidemiology Unit, Alfred Health, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Menno de Jong
- Department of Medical Microbiology, Amsterdam University Medical Center, University of Amsterdam, the Netherlands
| | | | - Lise Estcourt
- NHS Blood and Transplant, Bristol, United Kingdom
- Transfusion Medicine, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| | | | - Herman Goossens
- Department of Microbiology, Antwerp University Hospital, Antwerp, Belgium
| | - Cameron Green
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Rashan Haniffa
- Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Alisa M Higgins
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Christopher Horvat
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Sebastiaan J Hullegie
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Peter Kruger
- Intensive Care Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | | | - Patrick R Lawler
- Cardiac Intensive Care Unit, Peter Munk Cardiac Centre, University Health Network, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kelsey Linstrum
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Edward Litton
- School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
| | | | - John Marshall
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Daniel McAuley
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
| | | | - Shay McGuinness
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- The Health Research Council of New Zealand, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Bryan McVerry
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Stephanie Montgomery
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Paul Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Srinivas Murthy
- University of British Columbia School of Medicine, Vancouver, Canada
| | - Alistair Nichol
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Anesthesia and Intensive Care, St Vincent's University Hospital, Dublin, Ireland
- School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
- Department of Intensive Care, Alfred Health, Melbourne, Victoria, Australia
| | - Rachael Parke
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- The Health Research Council of New Zealand, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
- School of Nursing, University of Auckland, Auckland, New Zealand
| | - Jane Parker
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Kathryn Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | | | - Marlene Santos
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | | | - Christopher Seymour
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Anne Turner
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Frank van de Veerdonk
- Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Balasubramanian Venkatesh
- Southside Clinical Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- The George Institute for Global Health, Sydney, Australia
| | - Ryan Zarychanski
- Department of Medicine, Critical Care and Hematology/Medical Oncology, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Roger J Lewis
- Berry Consultants LLC, Austin, Texas
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
- Department of Emergency Medicine, David Geffen School of Medicine at University of California, Los Angeles
| | - Colin McArthur
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Steven A Webb
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
- St John of God Hospital, Subiaco, Western Australia, Australia
| | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine and Intensive Care Medicine, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Angus DC, Derde L, Al-Beidh F, Annane D, Arabi Y, Beane A, van Bentum-Puijk W, Berry L, Bhimani Z, Bonten M, Bradbury C, Brunkhorst F, Buxton M, Buzgau A, Cheng AC, de Jong M, Detry M, Estcourt L, Fitzgerald M, Goossens H, Green C, Haniffa R, Higgins AM, Horvat C, Hullegie SJ, Kruger P, Lamontagne F, Lawler PR, Linstrum K, Litton E, Lorenzi E, Marshall J, McAuley D, McGlothin A, McGuinness S, McVerry B, Montgomery S, Mouncey P, Murthy S, Nichol A, Parke R, Parker J, Rowan K, Sanil A, Santos M, Saunders C, Seymour C, Turner A, van de Veerdonk F, Venkatesh B, Zarychanski R, Berry S, Lewis RJ, McArthur C, Webb SA, Gordon AC, Al-Beidh F, Angus D, Annane D, Arabi Y, van Bentum-Puijk W, Berry S, Beane A, Bhimani Z, Bonten M, Bradbury C, Brunkhorst F, Buxton M, Cheng A, De Jong M, Derde L, Estcourt L, Goossens H, Gordon A, Green C, Haniffa R, Lamontagne F, Lawler P, Litton E, Marshall J, McArthur C, McAuley D, McGuinness S, McVerry B, Montgomery S, Mouncey P, Murthy S, Nichol A, Parke R, Rowan K, Seymour C, Turner A, van de Veerdonk F, Webb S, Zarychanski R, Campbell L, Forbes A, Gattas D, Heritier S, Higgins L, Kruger P, Peake S, Presneill J, Seppelt I, Trapani T, Young P, Bagshaw S, Daneman N, Ferguson N, Misak C, Santos M, Hullegie S, Pletz M, Rohde G, Rowan K, Alexander B, Basile K, Girard T, Horvat C, Huang D, Linstrum K, Vates J, Beasley R, Fowler R, McGloughlin S, Morpeth S, Paterson D, Venkatesh B, Uyeki T, Baillie K, Duffy E, Fowler R, Hills T, Orr K, Patanwala A, Tong S, Netea M, Bihari S, Carrier M, Fergusson D, Goligher E, Haidar G, Hunt B, Kumar A, Laffan M, Lawless P, Lother S, McCallum P, Middeldopr S, McQuilten Z, Neal M, Pasi J, Schutgens R, Stanworth S, Turgeon A, Weissman A, Adhikari N, Anstey M, Brant E, de Man A, Lamonagne F, Masse MH, Udy A, Arnold D, Begin P, Charlewood R, Chasse M, Coyne M, Cooper J, Daly J, Gosbell I, Harvala-Simmonds H, Hills T, MacLennan S, Menon D, McDyer J, Pridee N, Roberts D, Shankar-Hari M, Thomas H, Tinmouth A, Triulzi D, Walsh T, Wood E, Calfee C, O’Kane C, Shyamsundar M, Sinha P, Thompson T, Young I, Bihari S, Hodgson C, Laffey J, McAuley D, Orford N, Neto A, Detry M, Fitzgerald M, Lewis R, McGlothlin A, Sanil A, Saunders C, Berry L, Lorenzi E, Miller E, Singh V, Zammit C, van Bentum Puijk W, Bouwman W, Mangindaan Y, Parker L, Peters S, Rietveld I, Raymakers K, Ganpat R, Brillinger N, Markgraf R, Ainscough K, Brickell K, Anjum A, Lane JB, Richards-Belle A, Saull M, Wiley D, Bion J, Connor J, Gates S, Manax V, van der Poll T, Reynolds J, van Beurden M, Effelaar E, Schotsman J, Boyd C, Harland C, Shearer A, Wren J, Clermont G, Garrard W, Kalchthaler K, King A, Ricketts D, Malakoutis S, Marroquin O, Music E, Quinn K, Cate H, Pearson K, Collins J, Hanson J, Williams P, Jackson S, Asghar A, Dyas S, Sutu M, Murphy S, Williamson D, Mguni N, Potter A, Porter D, Goodwin J, Rook C, Harrison S, Williams H, Campbell H, Lomme K, Williamson J, Sheffield J, van’t Hoff W, McCracken P, Young M, Board J, Mart E, Knott C, Smith J, Boschert C, Affleck J, Ramanan M, D’Souza R, Pateman K, Shakih A, Cheung W, Kol M, Wong H, Shah A, Wagh A, Simpson J, Duke G, Chan P, Cartner B, Hunter S, Laver R, Shrestha T, Regli A, Pellicano A, McCullough J, Tallott M, Kumar N, Panwar R, Brinkerhoff G, Koppen C, Cazzola F, Brain M, Mineall S, Fischer R, Biradar V, Soar N, White H, Estensen K, Morrison L, Smith J, Cooper M, Health M, Shehabi Y, Al-Bassam W, Hulley A, Whitehead C, Lowrey J, Gresha R, Walsham J, Meyer J, Harward M, Venz E, Williams P, Kurenda C, Smith K, Smith M, Garcia R, Barge D, Byrne D, Byrne K, Driscoll A, Fortune L, Janin P, Yarad E, Hammond N, Bass F, Ashelford A, Waterson S, Wedd S, McNamara R, Buhr H, Coles J, Schweikert S, Wibrow B, Rauniyar R, Myers E, Fysh E, Dawda A, Mevavala B, Litton E, Ferrier J, Nair P, Buscher H, Reynolds C, Santamaria J, Barbazza L, Homes J, Smith R, Murray L, Brailsford J, Forbes L, Maguire T, Mariappa V, Smith J, Simpson S, Maiden M, Bone A, Horton M, Salerno T, Sterba M, Geng W, Depuydt P, De Waele J, De Bus L, Fierens J, Bracke S, Reeve B, Dechert W, Chassé M, Carrier FM, Boumahni D, Benettaib F, Ghamraoui A, Bellemare D, Cloutier È, Francoeur C, Lamontagne F, D’Aragon F, Carbonneau E, Leblond J, Vazquez-Grande G, Marten N, Wilson M, Albert M, Serri K, Cavayas A, Duplaix M, Williams V, Rochwerg B, Karachi T, Oczkowski S, Centofanti J, Millen T, Duan E, Tsang J, Patterson L, English S, Watpool I, Porteous R, Miezitis S, McIntyre L, Brochard L, Burns K, Sandhu G, Khalid I, Binnie A, Powell E, McMillan A, Luk T, Aref N, Andric Z, Cviljevic S, Đimoti R, Zapalac M, Mirković G, Baršić B, Kutleša M, Kotarski V, Vujaklija Brajković A, Babel J, Sever H, Dragija L, Kušan I, Vaara S, Pettilä L, Heinonen J, Kuitunen A, Karlsson S, Vahtera A, Kiiski H, Ristimäki S, Azaiz A, Charron C, Godement M, Geri G, Vieillard-Baron A, Pourcine F, Monchi M, Luis D, Mercier R, Sagnier A, Verrier N, Caplin C, Siami S, Aparicio C, Vautier S, Jeblaoui A, Fartoukh M, Courtin L, Labbe V, Leparco C, Muller G, Nay MA, Kamel T, Benzekri D, Jacquier S, Mercier E, Chartier D, Salmon C, Dequin P, Schneider F, Morel G, L’Hotellier S, Badie J, Berdaguer FD, Malfroy S, Mezher C, Bourgoin C, Megarbane B, Voicu S, Deye N, Malissin I, Sutterlin L, Guitton C, Darreau C, Landais M, Chudeau N, Robert A, Moine P, Heming N, Maxime V, Bossard I, Nicholier TB, Colin G, Zinzoni V, Maquigneau N, Finn A, Kreß G, Hoff U, Friedrich Hinrichs C, Nee J, Pletz M, Hagel S, Ankert J, Kolanos S, Bloos F, Petros S, Pasieka B, Kunz K, Appelt P, Schütze B, Kluge S, Nierhaus A, Jarczak D, Roedl K, Weismann D, Frey A, Klinikum Neukölln V, Reill L, Distler M, Maselli A, Bélteczki J, Magyar I, Fazekas Á, Kovács S, Szőke V, Szigligeti G, Leszkoven J, Collins D, Breen P, Frohlich S, Whelan R, McNicholas B, Scully M, Casey S, Kernan M, Doran P, O’Dywer M, Smyth M, Hayes L, Hoiting O, Peters M, Rengers E, Evers M, Prinssen A, Bosch Ziekenhuis J, Simons K, Rozendaal W, Polderman F, de Jager P, Moviat M, Paling A, Salet A, Rademaker E, Peters AL, de Jonge E, Wigbers J, Guilder E, Butler M, Cowdrey KA, Newby L, Chen Y, Simmonds C, McConnochie R, Ritzema Carter J, Henderson S, Van Der Heyden K, Mehrtens J, Williams T, Kazemi A, Song R, Lai V, Girijadevi D, Everitt R, Russell R, Hacking D, Buehner U, Williams E, Browne T, Grimwade K, Goodson J, Keet O, Callender O, Martynoga R, Trask K, Butler A, Schischka L, Young C, Lesona E, Olatunji S, Robertson Y, José N, Amaro dos Santos Catorze T, de Lima Pereira TNA, Neves Pessoa LM, Castro Ferreira RM, Pereira Sousa Bastos JM, Aysel Florescu S, Stanciu D, Zaharia MF, Kosa AG, Codreanu D, Marabi Y, Al Qasim E, Moneer Hagazy M, Al Swaidan L, Arishi H, Muñoz-Bermúdez R, Marin-Corral J, Salazar Degracia A, Parrilla Gómez F, Mateo López MI, Rodriguez Fernandez J, Cárcel Fernández S, Carmona Flores R, León López R, de la Fuente Martos C, Allan A, Polgarova P, Farahi N, McWilliam S, Hawcutt D, Rad L, O’Malley L, Whitbread J, Kelsall O, Wild L, Thrush J, Wood H, Austin K, Donnelly A, Kelly M, O’Kane S, McClintock D, Warnock M, Johnston P, Gallagher LJ, Mc Goldrick C, Mc Master M, Strzelecka A, Jha R, Kalogirou M, Ellis C, Krishnamurthy V, Deelchand V, Silversides J, McGuigan P, Ward K, O’Neill A, Finn S, Phillips B, Mullan D, Oritz-Ruiz de Gordoa L, Thomas M, Sweet K, Grimmer L, Johnson R, Pinnell J, Robinson M, Gledhill L, Wood T, Morgan M, Cole J, Hill H, Davies M, Antcliffe D, Templeton M, Rojo R, Coghlan P, Smee J, Mackay E, Cort J, Whileman A, Spencer T, Spittle N, Kasipandian V, Patel A, Allibone S, Genetu RM, Ramali M, Ghosh A, Bamford P, London E, Cawley K, Faulkner M, Jeffrey H, Smith T, Brewer C, Gregory J, Limb J, Cowton A, O’Brien J, Nikitas N, Wells C, Lankester L, Pulletz M, Williams P, Birch J, Wiseman S, Horton S, Alegria A, Turki S, Elsefi T, Crisp N, Allen L, McCullagh I, Robinson P, Hays C, Babio-Galan M, Stevenson H, Khare D, Pinder M, Selvamoni S, Gopinath A, Pugh R, Menzies D, Mackay C, Allan E, Davies G, Puxty K, McCue C, Cathcart S, Hickey N, Ireland J, Yusuff H, Isgro G, Brightling C, Bourne M, Craner M, Watters M, Prout R, Davies L, Pegler S, Kyeremeh L, Arbane G, Wilson K, Gomm L, Francia F, Brett S, Sousa Arias S, Elin Hall R, Budd J, Small C, Birch J, Collins E, Henning J, Bonner S, Hugill K, Cirstea E, Wilkinson D, Karlikowski M, Sutherland H, Wilhelmsen E, Woods J, North J, Sundaran D, Hollos L, Coburn S, Walsh J, Turns M, Hopkins P, Smith J, Noble H, Depante MT, Clarey E, Laha S, Verlander M, Williams A, Huckle A, Hall A, Cooke J, Gardiner-Hill C, Maloney C, Qureshi H, Flint N, Nicholson S, Southin S, Nicholson A, Borgatta B, Turner-Bone I, Reddy A, Wilding L, Chamara Warnapura L, Agno Sathianathan R, Golden D, Hart C, Jones J, Bannard-Smith J, Henry J, Birchall K, Pomeroy F, Quayle R, Makowski A, Misztal B, Ahmed I, KyereDiabour T, Naiker K, Stewart R, Mwaura E, Mew L, Wren L, Willams F, Innes R, Doble P, Hutter J, Shovelton C, Plumb B, Szakmany T, Hamlyn V, Hawkins N, Lewis S, Dell A, Gopal S, Ganguly S, Smallwood A, Harris N, Metherell S, Lazaro JM, Newman T, Fletcher S, Nortje J, Fottrell-Gould D, Randell G, Zaman M, Elmahi E, Jones A, Hall K, Mills G, Ryalls K, Bowler H, Sall J, Bourne R, Borrill Z, Duncan T, Lamb T, Shaw J, Fox C, Moreno Cuesta J, Xavier K, Purohit D, Elhassan M, Bakthavatsalam D, Rowland M, Hutton P, Bashyal A, Davidson N, Hird C, Chhablani M, Phalod G, Kirkby A, Archer S, Netherton K, Reschreiter H, Camsooksai J, Patch S, Jenkins S, Pogson D, Rose S, Daly Z, Brimfield L, Claridge H, Parekh D, Bergin C, Bates M, Dasgin J, McGhee C, Sim M, Hay SK, Henderson S, Phull MK, Zaidi A, Pogreban T, Rosaroso LP, Harvey D, Lowe B, Meredith M, Ryan L, Hormis A, Walker R, Collier D, Kimpton S, Oakley S, Rooney K, Rodden N, Hughes E, Thomson N, McGlynn D, Walden A, Jacques N, Coles H, Tilney E, Vowell E, Schuster-Bruce M, Pitts S, Miln R, Purandare L, Vamplew L, Spivey M, Bean S, Burt K, Moore L, Day C, Gibson C, Gordon E, Zitter L, Keenan S, Baker E, Cherian S, Cutler S, Roynon-Reed A, Harrington K, Raithatha A, Bauchmuller K, Ahmad N, Grecu I, Trodd D, Martin J, Wrey Brown C, Arias AM, Craven T, Hope D, Singleton J, Clark S, Rae N, Welters I, Hamilton DO, Williams K, Waugh V, Shaw D, Puthucheary Z, Martin T, Santos F, Uddin R, Somerville A, Tatham KC, Jhanji S, Black E, Dela Rosa A, Howle R, Tully R, Drummond A, Dearden J, Philbin J, Munt S, Vuylsteke A, Chan C, Victor S, Matsa R, Gellamucho M, Creagh-Brown B, Tooley J, Montague L, De Beaux F, Bullman L, Kersiake I, Demetriou C, Mitchard S, Ramos L, White K, Donnison P, Johns M, Casey R, Mattocks L, Salisbury S, Dark P, Claxton A, McLachlan D, Slevin K, Lee S, Hulme J, Joseph S, Kinney F, Senya HJ, Oborska A, Kayani A, Hadebe B, Orath Prabakaran R, Nichols L, Thomas M, Worner R, Faulkner B, Gendall E, Hayes K, Hamilton-Davies C, Chan C, Mfuko C, Abbass H, Mandadapu V, Leaver S, Forton D, Patel K, Paramasivam E, Powell M, Gould R, Wilby E, Howcroft C, Banach D, Fernández de Pinedo Artaraz Z, Cabreros L, White I, Croft M, Holland N, Pereira R, Zaki A, Johnson D, Jackson M, Garrard H, Juhaz V, Roy A, Rostron A, Woods L, Cornell S, Pillai S, Harford R, Rees T, Ivatt H, Sundara Raman A, Davey M, Lee K, Barber R, Chablani M, Brohi F, Jagannathan V, Clark M, Purvis S, Wetherill B, Dushianthan A, Cusack R, de Courcy-Golder K, Smith S, Jackson S, Attwood B, Parsons P, Page V, Zhao XB, Oza D, Rhodes J, Anderson T, Morris S, Xia Le Tai C, Thomas A, Keen A, Digby S, Cowley N, Wild L, Southern D, Reddy H, Campbell A, Watkins C, Smuts S, Touma O, Barnes N, Alexander P, Felton T, Ferguson S, Sellers K, Bradley-Potts J, Yates D, Birkinshaw I, Kell K, Marshall N, Carr-Knott L, Summers C. Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial. JAMA 2020; 324:1317-1329. [PMID: 32876697 PMCID: PMC7489418 DOI: 10.1001/jama.2020.17022] [Citation(s) in RCA: 542] [Impact Index Per Article: 135.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
IMPORTANCE Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited. OBJECTIVE To determine whether hydrocortisone improves outcome for patients with severe COVID-19. DESIGN, SETTING, AND PARTICIPANTS An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020. INTERVENTIONS The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108). MAIN OUTCOMES AND MEASURES The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%). RESULTS After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively. CONCLUSIONS AND RELEVANCE Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02735707.
Collapse
Affiliation(s)
- Derek C Angus
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Lennie Derde
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- Intensive Care Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Farah Al-Beidh
- Division of Anaesthetics, Pain Medicine and Intensive Care Medicine, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Djillali Annane
- Intensive Care Unit, Raymond Poincaré Hospital (AP-HP), Paris, France
- Simone Veil School of Medicine, University of Versailles, Versailles, France
- University Paris Saclay, Garches, France
| | - Yaseen Arabi
- Intensive Care Department, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Abigail Beane
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Wilma van Bentum-Puijk
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Zahra Bhimani
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Marc Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Charlotte Bradbury
- Bristol Royal Informatory, Bristol, United Kingdom
- University of Bristol, Bristol, United Kingdom
| | - Frank Brunkhorst
- Center for Clinical Studies and Center for Sepsis Control and Care (CSCC), Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Meredith Buxton
- Global Coalition for Adaptive Research, San Francisco, California
| | - Adrian Buzgau
- Helix, Monash University, Melbourne, Victoria, Australia
| | - Allen C Cheng
- Infection Prevention and Healthcare Epidemiology Unit, Alfred Health, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Menno de Jong
- Department of Medical Microbiology, Amsterdam University Medical Center, University of Amsterdam, the Netherlands
| | | | - Lise Estcourt
- NHS Blood and Transplant, Bristol, United Kingdom
- Transfusion Medicine, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| | | | - Herman Goossens
- Department of Microbiology, Antwerp University Hospital, Antwerp, Belgium
| | - Cameron Green
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Rashan Haniffa
- Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Alisa M Higgins
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Christopher Horvat
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Sebastiaan J Hullegie
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Peter Kruger
- Intensive Care Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | | | - Patrick R Lawler
- Cardiac Intensive Care Unit, Peter Munk Cardiac Centre, University Health Network, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kelsey Linstrum
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Edward Litton
- School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
| | | | - John Marshall
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Daniel McAuley
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
| | | | - Shay McGuinness
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- The Health Research Council of New Zealand, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Bryan McVerry
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Stephanie Montgomery
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Paul Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Srinivas Murthy
- University of British Columbia School of Medicine, Vancouver, Canada
| | - Alistair Nichol
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Anesthesia and Intensive Care, St Vincent's University Hospital, Dublin, Ireland
- School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
- Department of Intensive Care, Alfred Health, Melbourne, Victoria, Australia
| | - Rachael Parke
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- The Health Research Council of New Zealand, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
- School of Nursing, University of Auckland, Auckland, New Zealand
| | - Jane Parker
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Kathryn Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | | | - Marlene Santos
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | | | - Christopher Seymour
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Anne Turner
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Frank van de Veerdonk
- Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Balasubramanian Venkatesh
- Southside Clinical Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- The George Institute for Global Health, Sydney, Australia
| | - Ryan Zarychanski
- Department of Medicine, Critical Care and Hematology/Medical Oncology, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Roger J Lewis
- Berry Consultants LLC, Austin, Texas
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
- Department of Emergency Medicine, David Geffen School of Medicine at University of California, Los Angeles
| | - Colin McArthur
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Steven A Webb
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
- St John of God Hospital, Subiaco, Western Australia, Australia
| | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine and Intensive Care Medicine, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Weiss MJ, English SW, D'Aragon F, Lauzier F, Turgeon AF, Dhanani S, McIntyre L, Carvalho LP, Yu M, Shemie SD, Knoll G, Fergusson DA, Anthony SJ, Haj-Moustafa A, Hartell D, Mohr J, Chassé M. Survey of Canadian critical care physicians' knowledge and attitudes towards legislative aspects of the deceased organ donation system. Can J Anaesth 2020; 67:1349-1358. [PMID: 32696225 DOI: 10.1007/s12630-020-01756-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/28/2020] [Accepted: 04/28/2020] [Indexed: 10/23/2022] Open
Abstract
PURPOSE We surveyed Canadian critical care physicians who may care for patients who are potential organ donors to understand their attitudes and knowledge of legislation governing the deceased organ donation system. METHODS We used a web-based, self-administered survey that included questions related to opt-out consent and mandatory referral legislation. Potential participants were identified through membership lists of professional societies and manual searches. We designed our survey using standardized methods and administered it in February and March 2018. RESULTS Fifty percent (263/529) of potential participants completed the questionnaire. A majority (61%; 144/235) supported a change towards an opt-out consent model, and 77% (181/235) stated they believe it would increase donation rates. Asked if opt-out consent would change their practices, 71% (166/235) stated an opt-out model would not change how or if they approach families to discuss donation. Fifty-six percent (139/249) supported mandatory referral laws, while only 42% (93/219) of those working in provinces with mandatory referral correctly stated that such laws exist in their province. Respondents gave variable responses on who should be accountable when patients are not referred, and 16% (40/249) believed no one should be held accountable. CONCLUSIONS While a majority of critical care physicians supported opt-out consent and mandatory referral, many were neutral or against it. Many were unaware of existing laws and had variable opinions on how to ensure accountability. Efforts to increase understanding of how legislative models influence practice are required for any law to achieve its desired effect.
Collapse
Affiliation(s)
- Matthew J Weiss
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Université Laval, Québec, QC, Canada.
- Donation and Transplantation, Canadian Blood Services, Ottawa, ON, Canada.
- Transplant Québec, Montréal, QC, Canada.
- Canadian Donation and Transplant Research Program, Ottawa, ON, Canada.
| | - Shane W English
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Frederick D'Aragon
- Canadian Donation and Transplant Research Program, Ottawa, ON, Canada
- Department of Anesthesiology, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - François Lauzier
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Université Laval, Québec, QC, Canada
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec, QC, Canada
- Department of Medicine, Université Laval, Québec, QC, Canada
| | - Alexis F Turgeon
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Université Laval, Québec, QC, Canada
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec, QC, Canada
| | - Sonny Dhanani
- Canadian Donation and Transplant Research Program, Ottawa, ON, Canada
- Division of Critical Care, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Lauralyn McIntyre
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Livia P Carvalho
- Carrefour de l'innovation, Centre de Recherche du CHUM, Montréal, QC, Canada
| | - Michael Yu
- Carrefour de l'innovation, Centre de Recherche du CHUM, Montréal, QC, Canada
| | - Sam D Shemie
- Donation and Transplantation, Canadian Blood Services, Ottawa, ON, Canada
- Division of Critical Care, Montréal Children's Hospital, Montréal, QC, Canada
- McGill University Health Centre and Research Institute, Montréal, QC, Canada
| | - Gregory Knoll
- Canadian Donation and Transplant Research Program, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Dean A Fergusson
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Samantha J Anthony
- Canadian Donation and Transplant Research Program, Ottawa, ON, Canada
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - Adnan Haj-Moustafa
- Carrefour de l'innovation, Centre de Recherche du CHUM, Montréal, QC, Canada
| | - David Hartell
- Canadian Donation and Transplant Research Program, Ottawa, ON, Canada
| | - Jim Mohr
- Donation and Transplantation, Canadian Blood Services, Ottawa, ON, Canada
| | - Michaël Chassé
- Canadian Donation and Transplant Research Program, Ottawa, ON, Canada
- Carrefour de l'innovation, Centre de Recherche du CHUM, Montréal, QC, Canada
- Division of Critical Care, Department of Medicine, Centre Hospitalier de L'Université de Montréal, Montréal, QC, Canada
- Department of Medicine, Université de Montréal, Montréal, QC, Canada
| |
Collapse
|
24
|
Taylor C, Yang L, Finfer S, Machado FR, YouZhong A, Billot L, Bloos F, Bozza F, Cavalcanti AB, Correa M, Du B, Hjortrup PB, McIntyre L, Saxena M, Schortgen F, Watts NR, Myburgh J, Thompson K, Hammond NE. An international comparison of the cost of fluid resuscitation therapies. Aust Crit Care 2020; 34:23-32. [PMID: 32828672 DOI: 10.1016/j.aucc.2020.06.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/31/2020] [Accepted: 06/01/2020] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE Fluid resuscitation is a ubiquitous intervention in the management of patients treated in the intensive care unit, which has implications for intensive care unit resourcing and budgets. Our objective was to calculate the relative cost of resuscitation fluids in several countries to inform future economic evaluations. METHODS We collected site-level data regarding the availability and cost of fluids as part of an international survey. We normalised costs to net present values using purchasing power parities and published inflation figures. Costs were also adjusted for equi-effective dosing based on intravascular volume expansion effectiveness and expressed as US dollars (USD) per 100 mL crystalloid equivalent. RESULTS A total of 187 sites had access to cost data. Between countries, there was an approximate six fold variation in the cost of crystalloids and colloids overall. The average cost for crystalloids overall was less than 1 USD per 100 mL. In contrast, colloid fluids had higher average costs (59 USD per 100 mL). After adjusting for equi-effective dosing, saline was ∼27 times less costly than albumin (saline: 0.6 USD per 100 mL crystalloid equivalent; albumin 4-5%: 16.4 USD; albumin 20-25%: 15.8 USD) and ∼4 times less costly than hydroxyethyl starch solution (saline: 0.6 USD; hydroxyethyl starch solution: 2.5 USD). Buffered salt solutions, such as compound sodium acetate solutions (e.g., Plasmalyte®), had the highest average cost of crystalloid fluids, costing between 3 and 4 USD per 100 mL. CONCLUSION The cost of fluid varies substantially between fluid types and between countries, although normal (0.9%) saline is consistently less costly than colloid preparations and some buffered salt solutions. These data can be used to inform future economic evaluations of fluid preparations.
Collapse
Affiliation(s)
- Colman Taylor
- Critical Care Division, The George Institute for Global Health, Sydney, Australia; Faculty of Medicine, University of New South Wales, Sydney, Australia.
| | - Li Yang
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
| | - Simon Finfer
- Critical Care Division, The George Institute for Global Health, Sydney, Australia; Faculty of Medicine, University of New South Wales, Sydney, Australia; Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, Australia
| | - Flavia R Machado
- Anesthesiology, Pain and Intensive Care Department, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - An YouZhong
- Department of Critical Care Medicine, Peking University People's Hospital, Beijing, China
| | - Laurent Billot
- Faculty of Medicine, University of New South Wales, Sydney, Australia; Statistics Division, The George Institute for Global Health, Sydney, Australia
| | - Frank Bloos
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Fernando Bozza
- D'Or Institute for Research and Education, Rio de Janeiro, Brazil
| | | | - Maryam Correa
- Critical Care Division, The George Institute for Global Health, Sydney, Australia; Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Bin Du
- Medical Intensive Care Unit, Peking Union Medical College Hospital, Beijing, China
| | - Peter B Hjortrup
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Lauralyn McIntyre
- Department of Medicine (Critical Care), The Ottawa Hospital Research Institute, Ottawa, Canada
| | - Manoj Saxena
- Critical Care Division, The George Institute for Global Health, Sydney, Australia; Faculty of Medicine, University of New South Wales, Sydney, Australia; Department of Intensive Care, Bankstown Hospital, Bankstown, Australia
| | - Frédérique Schortgen
- Assistance Publique-Hôpitaux de Paris, Réanimation Médicale Groupe Hospitalier Henri Mondor, Créteil, France
| | - Nicola R Watts
- Critical Care Division, The George Institute for Global Health, Sydney, Australia; Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - John Myburgh
- Critical Care Division, The George Institute for Global Health, Sydney, Australia; Faculty of Medicine, University of New South Wales, Sydney, Australia; Department of Intensive Care Medicine, St. George Hospital, Kograh, Australia
| | - Kelly Thompson
- Critical Care Division, The George Institute for Global Health, Sydney, Australia; Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Naomi E Hammond
- Critical Care Division, The George Institute for Global Health, Sydney, Australia; Faculty of Medicine, University of New South Wales, Sydney, Australia.
| | | |
Collapse
|
25
|
Dave C, McRae A, Doxtator E, Mei SHJ, Sullivan K, Wolfe D, Champagne J, McIntyre L. Comparison of freshly cultured versus freshly thawed (cryopreserved) mesenchymal stem cells in preclinical in vivo models of inflammation: a protocol for a preclinical systematic review and meta-analysis. Syst Rev 2020; 9:188. [PMID: 32814560 PMCID: PMC7437051 DOI: 10.1186/s13643-020-01437-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 07/29/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Mesenchymal stem cells (MSCs) are multipotent cells that demonstrate therapeutic potential for the treatment of acute and chronic inflammatory-mediated conditions. Especially for acute conditions, it is critical to have a readily available freshly thawed (cryopreserved) MSC product for rapid administration. Although controversial, some studies suggest that MSCs may lose their functionality with cryopreservation which in turn could render them non-efficacious. OBJECTIVE In controlled preclinical in vivo models of inflammation, to determine if there are differences in surrogate measures of preclinical efficacy between freshly cultured and freshly thawed MSCs METHODS/DESIGN: A systematic search for pre-clinical in vivo inflammatory model studies will compare freshly cultured to freshly thawed MSCs from any source. The primary outcomes will include measures of in vivo preclinical efficacy; secondary outcomes will include measures of in vitro MSC potency. Electronic searches for MEDLINE and EMBASE will be constructed and reviewed by the Peer Review of Electronic Search Strategies (PRESS) process. If applicable, study outcomes will be meta-analyzed using a random effects model. Risk of bias will be assessed by the SYRCLE "Risk of Bias" assessment tool for preclinical in vivo studies. DISCUSSION The results of this systematic review will provide translational scientists, clinical trialists, health regulators, and the clinical and public community with the current pre-clinical evidence base related to the efficacy and potency of freshly cultured versus freshly thawed MSCs, help identify evidence gaps, and guide future related research. SYSTEMATIC REVIEW REGISTRATION Protocol is submitted to PROSPERO for registration (pending confirmation) and will be submitted to Collaborative Approach to Meta-Analysis and Review of Animal Data from Experimental Studies (CAMARADES) for public posting.
Collapse
Affiliation(s)
- Chintan Dave
- Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - Andrea McRae
- Sinclair Centre for Regenerative Medicine, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Emily Doxtator
- Sinclair Centre for Regenerative Medicine, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Shirley H J Mei
- Sinclair Centre for Regenerative Medicine, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Katrina Sullivan
- Sinclair Centre for Regenerative Medicine, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Dianna Wolfe
- Knowledge Synthesis Group, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Josee Champagne
- Sinclair Centre for Regenerative Medicine, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Lauralyn McIntyre
- Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada. .,Division of Critical Care, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada.
| |
Collapse
|
26
|
English SW, Saigle V, McIntyre L, Chassé M, Fergusson D, Turgeon AF, Lauzier F, Griesdale D, Garland A, Zarychanski R, Algird A, Wiens EJ, Hu V, Dutta P, Boun V, van Walraven C. External validation demonstrated the Ottawa SAH prediction models can identify pSAH using health administrative data. J Clin Epidemiol 2020; 126:122-130. [PMID: 32619751 DOI: 10.1016/j.jclinepi.2020.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 05/22/2020] [Accepted: 06/23/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES The objective of the study is to externally validate three primary subarachnoid hemorrhage (pSAH) identification models. STUDY DESIGN AND SETTING We evaluated three models that identify pSAH using recursive partitioning (A), logistic regression (B), and a prevalence-adjusted logistic regression(C), respectively. Blinded chart review and/or linkage to existing registries determined pSAH status. We included all patients aged ≥18 in four participating center registries or whose discharge abstracts contained ≥1 administrative codes of interest between January 1, 2012 and December 31, 2013. RESULTS A total of 3,262 of 193,190 admissions underwent chart review (n = 2,493) or registry linkage (n = 769). A total of 657 had pSAH confirmed (20·1% sample, 0·34% admissions). The sensitivity, specificity, and positive predictive value (PPV) were as follows: i) model A: 98·3% (97·0-99·2), 53·5% (51·5-55·4), and 34·8% (32·6-37·0); ii) model B (score ≥6): 98·0% (96·6-98·9), 47·4% (45·5-49·4), and 32·0% (30·0-34·1); and iii) model C (score ≥2): 95·7% (93·9-97·2), 85·5% (84·0-86·8), and 62·3 (59·3-65·3), respectively. Model C scores of 0, 1, 2, 3, or 4 had probabilities of 0·5% (0·2-1·5), 1·5% (1·0-2·2), 24·8% (21·0-29·0), 90·0% (86·8-92·0), and 97·8% (88·7-99·6), without significant difference between centers (P = 0·86). The PPV of the International Classification of Diseases code (I60) was 63·0% (95% confidence interval: 60·0-66·0). CONCLUSIONS All three models were highly sensitive for pSAH. Model C could be used to adjust for misclassification bias.
Collapse
Affiliation(s)
- Shane W English
- Department of Medicine (Critical Care), uOttawa, Civic Campus Room F202, 1053 Carling Avenue, Ottawa, Ontario K1Y 4E9, Canada; Clinical Epidemiology Program (CEP), Ottawa Hospital Research Institute (OHRI), Civic Campus Room F202, 1053 Carling Avenue, Ottawa, Ontario K1Y 4E9, Canada.
| | - Victoria Saigle
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital - General Campus, 501 Smyth Road, Ottawa, Ontario K1H 8L6, Canada
| | - Lauralyn McIntyre
- Department of Medicine (Critical Care), uOttawa, Civic Campus Room F202, 1053 Carling Avenue, Ottawa, Ontario K1Y 4E9, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital - General Campus, 501 Smyth Road, Ottawa, Ontario K1H 8L6, Canada
| | - Michaël Chassé
- Division of Critical Care, Department of Medicine, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, 900 St Denis Street, Montreal, Quebec H2X 0A9, Canada
| | - Dean Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, The Ottawa Hospital - General Campus, 501 Smyth Road, Ottawa, Ontario K1H 8L6, Canada; Department of Medicine (Clinical Epidemiology), uOttawa, 501 Smyth Road, Ottawa, Ontario K1H 8L6, Canada
| | - Alexis F Turgeon
- Centre de recherche du CHU de Québec - Université Laval, Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), 1050 Chemin Sainte-Foy, Local K0-03, Québec, Québec G1S 4L8, Canada; Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, 2325 Rue de l'Université, Québec, Québec G1V 0A6, Canada
| | - François Lauzier
- Centre de recherche du Centre Hospitalier de l'Université de Québec, Université Laval, Québec City, Québec, Canada; Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, and Department of Medicine, Université Laval, 2325 Rue de l'Université, Québec, Québec G1V 0A6, Canada
| | - Donald Griesdale
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, 2176 Health Sciences Mall, Vancouver, British Columbia V6T 1Z3, Canada
| | - Allan Garland
- Sections of Critical Care and Respirology, Department of Internal Medicine, University of Manitoba, Health Sciences Centre, University of Manitoba, 820 Sherbrook Street, Winnipeg, Manitoba R3A 1R9, Canada
| | - Ryan Zarychanski
- Department of Internal Medicine, Sections of Critical Care and Hematology/Medical Oncology, University of Manitoba, Health Sciences Centre, University of Manitoba, 820 Sherbrook Street, Winnipeg Manitoba R3A 1R9, Canada
| | - Almunder Algird
- Department of Neurosurgery, McMaster University, Hamilton Health Sciences, 1200 Main St W, Hamilton, Ontario L8N 3Z5, Canada
| | - Evan J Wiens
- Department of Internal Medicine, University of Manitoba, Health Sciences Centre, University of Manitoba, 820 Sherbrook Street, Winnipeg Manitoba R3A 1R9, Canada
| | - Vivien Hu
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, 2176 Health Sciences Mall, Vancouver, British Columbia V6T 1Z3, Canada
| | - Pallavi Dutta
- Faculty of Health Sciences, McMaster University, 1200 Main St W, Hamilton, Ontario L8N 3Z5, Canada
| | - Vincent Boun
- Centre de recherche du CHU de Québec - Université Laval, Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), 1050 Chemin Sainte-Foy, Local K0-03, Québec, Québec G1S 4L8, Canada
| | - Carl van Walraven
- Department of Medicine (Clinical Epidemiology), uOttawa, 501 Smyth Road, Ottawa, Ontario K1H 8L6, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, 1053 Carling Avenue Building, 1st Floor, Ottawa, Ontario K1Y 4E9, Canada; ICES-uOttawa, Administrative Services, 1053 Carling Avenue Building, 1st Floor, Ottawa, Ontario K1Y 4E9, Canada
| |
Collapse
|
27
|
Foster M, Presseau J, McCleary N, Carroll K, McIntyre L, Hutton B, Brehaut J. Audit and feedback to improve laboratory test and transfusion ordering in critical care: a systematic review. Implement Sci 2020; 15:46. [PMID: 32560666 PMCID: PMC7303577 DOI: 10.1186/s13012-020-00981-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Accepted: 03/12/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Laboratory tests and transfusions are sometimes ordered inappropriately, particularly in the critical care setting, which sees frequent use of both. Audit and Feedback (A&F) is a potentially useful intervention for modifying healthcare provider behaviors, but its application to the complex, team-based environment of critical care is not well understood. We conducted a systematic review of the literature on A&F interventions for improving test or transfusion ordering in the critical care setting. METHODS Five databases, two registries, and the bibliographies of relevant articles were searched. We included critical care studies that assessed the use of A&F targeting healthcare provider behaviors, alone or in combination with other interventions to improve test and transfusion ordering, as compared to historical practice, no intervention, or another healthcare behaviour change intervention. Studies were included only if they reported laboratory test or transfusion orders, or the appropriateness of orders, as outcomes. There were no restrictions based on study design, date of publication, or follow-up time. Intervention characteristics and absolute differences in outcomes were summarized. The quality of individual studies was assessed using a modified version of the Effective Practice and Organisation of Care Cochrane Review Group's criteria. RESULTS We identified 16 studies, including 13 uncontrolled before-after studies, one randomized controlled trial, one controlled before-after study, and one controlled clinical trial (quasi-experimental). These studies described 17 interventions, mostly (88%) multifaceted interventions with an A&F component. Feedback was most often provided in a written format only (41%), more than once (53%), and most often only provided data aggregated to the group-level (41%). Most studies saw a change in the hypothesized direction, but not all studies provided statistical analyses to formally test improvement. Overall study quality was low, with studies often lacking a concurrent control group. CONCLUSIONS Our review summarizes characteristics of A&F interventions implemented in the critical care context, points to some mechanisms by which A&F might be made more effective in this setting, and provides an overview of how the appropriateness of orders was reported. Our findings suggest that A&F can be effective in the context of critical care; however, further research is required to characterize approaches that optimize the effectiveness in this setting alongside more rigorous evaluation methods. TRIAL REGISTRATION PROSPERO CRD42016051941.
Collapse
Affiliation(s)
- Madison Foster
- School of Epidemiology and Public Health, University of Ottawa, 451 Smyth Road, Ottawa, ON K1H 8M5 Canada
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON K1H 8L6 Canada
| | - Justin Presseau
- School of Epidemiology and Public Health, University of Ottawa, 451 Smyth Road, Ottawa, ON K1H 8M5 Canada
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON K1H 8L6 Canada
- School of Psychology, University of Ottawa, 136 Jean-Jacques Lussier, Vanier Hall, Ottawa, ON K1N 6N5 Canada
| | - Nicola McCleary
- School of Epidemiology and Public Health, University of Ottawa, 451 Smyth Road, Ottawa, ON K1H 8M5 Canada
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON K1H 8L6 Canada
| | - Kelly Carroll
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON K1H 8L6 Canada
| | - Lauralyn McIntyre
- School of Epidemiology and Public Health, University of Ottawa, 451 Smyth Road, Ottawa, ON K1H 8M5 Canada
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON K1H 8L6 Canada
- Department of Critical Care Medicine, The Ottawa Hospital, General Campus, 501 Smyth Road, Ottawa, ON K1H 8L6 Canada
| | - Brian Hutton
- School of Epidemiology and Public Health, University of Ottawa, 451 Smyth Road, Ottawa, ON K1H 8M5 Canada
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON K1H 8L6 Canada
- Ottawa Hospital Research Institute, Knowledge Synthesis Unit, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON K1H 8L6 Canada
| | - Jamie Brehaut
- School of Epidemiology and Public Health, University of Ottawa, 451 Smyth Road, Ottawa, ON K1H 8M5 Canada
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, The Ottawa Hospital, General Campus, 501 Smyth Road, Centre for Practice Changing Research, Box 201B, Ottawa, ON K1H 8L6 Canada
| |
Collapse
|
28
|
Souza-Moreira L, Tan Y, Virgo J, Wang J, Salkhordeh M, Watpool I, McIntyre L, Stewart D, Mei S. Whole transcriptome RNA sequencing analysis on mesenchymal stem cells preconditioned by inflammatory stimuli. Cytotherapy 2020. [DOI: 10.1016/j.jcyt.2020.03.189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
29
|
Weiss MJ, English SW, D'Aragon F, Lauzier F, Turgeon AF, Dhanani S, McIntyre L, Shemie SD, Knoll G, Fergusson DA, Anthony SJ, Haj-Moustafa A, Hartell D, Mohr J, Chassé M. Survey of Canadian intensivists on physician non-referral and family override of deceased organ donation. Can J Anaesth 2020; 67:313-323. [PMID: 31768789 DOI: 10.1007/s12630-019-01538-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 08/08/2019] [Accepted: 09/04/2019] [Indexed: 02/07/2023] Open
Abstract
PURPOSE Intensive care physicians play an important role in the identification and referral of potential organ donors in Canada. Nevertheless, little is known about intensivists' attitudes or behaviours in situations where families override previously expressed consent to donate; nor why physicians elect not to refer patients who are potential donors to provincial organ donation organizations (physician non-referral). METHODS We integrated questions regarding family override and physician non-referral into an online, self-administered survey of Canadian intensivists. We report results descriptively. RESULTS Fifty percent of targeted respondents (n = 550) participated. Fifty-five percent reported having witnessed family override situations and 44% reported having personally not referred patients who were potential donors. Fifty-six percent of respondents stated they would not pursue donation in the face of family override; 2% stated they would continue with the donation process. Fear of loss of trust in the donation system (81%) and obligation to respect the grief and desires of surrogate decision makers (71%) were frequently reported reasons to respect family override requests. Respondents who chose not to refer patients often did so based on organ dysfunction they assumed would preclude donation (59%), or a perception that the family was too distressed to consider donation (42%). No respondents reported that personally held beliefs against organ donation influenced their decision. CONCLUSION Physicians caring for patients who are potential organ donors commonly encounter both family override and physician non-referral situations. Knowledge translation of optimal practices in identification and referral could help ensure that physician practices align with legal requirements and practice recommendations.
Collapse
Affiliation(s)
- Matthew J Weiss
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Université Laval, Québec, QC, Canada.
- Donation and Transplantation, Canadian Blood Services, Ottawa, ON, Canada.
- Transplant Québec, Montréal, QC, Canada.
- Canadian Donation and Transplant Research Program, Ottawa, ON, Canada.
| | - Shane W English
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Frederick D'Aragon
- Canadian Donation and Transplant Research Program, Ottawa, ON, Canada
- Department of Anesthesiology, Université de Sherbrooke, Sherbrooke, QC, Canada
| | - François Lauzier
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Université Laval, Québec, QC, Canada
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec, QC, Canada
- Department of Medicine, Université Laval, Québec, QC, Canada
| | - Alexis F Turgeon
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Université Laval, Québec, QC, Canada
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec, QC, Canada
| | - Sonny Dhanani
- Canadian Donation and Transplant Research Program, Ottawa, ON, Canada
- Division of Critical Care, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Lauralyn McIntyre
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Sam D Shemie
- Donation and Transplantation, Canadian Blood Services, Ottawa, ON, Canada
- Division of Critical Care, Montréal Children's Hospital, McGill University Health Centre and Research Institute, Montreal, QC, Canada
- McGill University, Montréal, QC, Canada
| | - Gregory Knoll
- Canadian Donation and Transplant Research Program, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Dean A Fergusson
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Samantha J Anthony
- Canadian Donation and Transplant Research Program, Ottawa, ON, Canada
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - Adnan Haj-Moustafa
- Carrefour de l'Innovation, Centre de Recherche du CHUM, Montréal, QC, Canada
| | - David Hartell
- Canadian Donation and Transplant Research Program, Ottawa, ON, Canada
| | - Jim Mohr
- Donation and Transplantation, Canadian Blood Services, Ottawa, ON, Canada
| | - Michaël Chassé
- Canadian Donation and Transplant Research Program, Ottawa, ON, Canada
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, Toronto, ON, Canada
- Carrefour de l'Innovation, Centre de Recherche du CHUM, Montréal, QC, Canada
- Division of Critical Care, Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montréal, QC, Canada
- Department of Medicine, University of Montréal, Montréal, QC, Canada
| |
Collapse
|
30
|
Thompson M, Mei SH, Wolfe D, Champagne J, Fergusson D, Stewart DJ, Sullivan KJ, Doxtator E, Lalu M, English SW, Granton J, Hutton B, Marshall J, Maybee A, Walley KR, Santos CD, Winston B, McIntyre L. Cell therapy with intravascular administration of mesenchymal stromal cells continues to appear safe: An updated systematic review and meta-analysis. EClinicalMedicine 2020; 19:100249. [PMID: 31989101 PMCID: PMC6970160 DOI: 10.1016/j.eclinm.2019.100249] [Citation(s) in RCA: 136] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 12/04/2019] [Accepted: 12/17/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Characterization of the mesenchymal stromal cell (MSC) safety profile is important as this novel therapy continues to be evaluated in clinical trials for various inflammatory conditions. Due to an increase in published randomized controlled trials (RCTs) from 2012-2019, we performed an updated systematic review to further characterize the MSC safety profile. METHODS MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and Web of Science (to May 2018) were searched. RCTs that compared intravascular delivery of MSCs to controls in adult populations were included. Pre-specified adverse events were grouped according to: (1) immediate, (2) infection, (3) thrombotic/embolic, and (4) longer-term events (mortality, malignancy). Adverse events were pooled and meta-analyzed by fitting inverse-variance binary random effects models. Primary and secondary clinical efficacy endpoints were summarized descriptively. FINDINGS 7473 citations were reviewed and 55 studies met inclusion criteria (n = 2696 patients). MSCs as compared to controls were associated with an increased risk of fever (Relative Risk (RR) = 2·48, 95% Confidence Interval (CI) = 1·27-4·86; I2 = 0%), but not non-fever acute infusional toxicity, infection, thrombotic/embolic events, death, or malignancy (RR = 1·16, 0·99, 1·14, 0·78, 0·93; 95% CI = 0·70-1·91, 0·81-1·21, 0·67-1·95, 0·65-0·94, 0·60-1·45; I2 = 0%, 0%, 0%, 0%, 0%). No included trials were ended prematurely due to safety concerns. INTERPRETATIONS MSC therapy continues to exhibit a favourable safety profile. Future trials should continue to strengthen study rigor, reporting of MSC characterization, and adverse events. FUNDING Stem Cell Network, Ontario Institute for Regenerative Medicine and Ontario Research Fund.
Collapse
Affiliation(s)
- Mary Thompson
- Clinical Epidemiology Program (CEP), Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Shirley H.J. Mei
- Regenerative Medicine Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dianna Wolfe
- Clinical Epidemiology Program (CEP), Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Josée Champagne
- Clinical Epidemiology Program (CEP), Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dean Fergusson
- Clinical Epidemiology Program (CEP), Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Duncan J. Stewart
- Regenerative Medicine Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Katrina J. Sullivan
- Clinical Epidemiology Program (CEP), Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Emily Doxtator
- Clinical Epidemiology Program (CEP), Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Manoj Lalu
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Shane W. English
- Clinical Epidemiology Program (CEP), Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - John Granton
- Department of Medicine (Critical Care), University of Toronto, Toronto, Ontario, Canada
| | - Brian Hutton
- Clinical Epidemiology Program (CEP), Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - John Marshall
- Department of Surgery (Critical Care), University of Toronto, Toronto, Ontario, Canada
| | - Alies Maybee
- Patient Advisors Network, Toronto, Ontario, Canada
| | - Keith R. Walley
- Centre for Heart Lung Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Claudia Dos Santos
- Department of Surgery (Critical Care), University of Toronto, Toronto, Ontario, Canada
| | - Brent Winston
- Department of Critical Care, Medicine, and Biochemistry and Microbiology, University of Calgary, Calgary, Alberta, Canada
| | - Lauralyn McIntyre
- Clinical Epidemiology Program (CEP), Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| |
Collapse
|
31
|
Daneman N, Rishu AH, Pinto R, Arabi Y, Belley-Cote EP, Cirone R, Downing M, Cook DJ, Hall R, McGuinness S, McIntyre L, Muscedere J, Parke R, Reynolds S, Rogers BA, Shehabi Y, Shin P, Whitlock R, Fowler RA. A pilot randomized controlled trial of 7 versus 14 days of antibiotic treatment for bloodstream infection on non-intensive care versus intensive care wards. Trials 2020; 21:92. [PMID: 31941546 PMCID: PMC6964073 DOI: 10.1186/s13063-019-4033-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 12/29/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The optimal treatment duration for patients with bloodstream infection is understudied. The Bacteremia Antibiotic Length Actually Needed for Clinical Effectiveness (BALANCE) pilot randomized clinical trial (RCT) determined that it was feasible to enroll and randomize intensive care unit (ICU) patients with bloodstream infection to 7 versus 14 days of treatment, and served as the vanguard for the ongoing BALANCE main RCT. We performed this BALANCE-Ward pilot RCT to examine the feasibility and impact of potentially extending the BALANCE main RCT to include patients hospitalized on non-ICU wards. METHODS We conducted an open pilot RCT among a subset of six sites participating in the ongoing BALANCE RCT, randomizing patients with positive non-Staphylococcus aureus blood cultures on non-ICU wards to 7 versus 14 days of antibiotic treatment. The co-primary feasibility outcomes were recruitment rate and adherence to treatment duration protocol. We compared feasibility outcomes, patient/pathogen characteristics, and overall outcomes among those enrolled in this BALANCE-Ward and prior BALANCE-ICU pilot RCTs. We estimated the sample size and non-inferiority margin impacts of expanding the BALANCE main RCT to include non-ICU patients. RESULTS A total of 134 patients were recruited over 47 site-months (mean 2.9 patients/site-month, median 1.0, range 0.1-4.4 patients/site-month). The overall recruitment rate exceeded the BALANCE-ICU pilot RCT (mean 1.10 patients/site-month, p < 0.0001). Overall protocol adherence also exceeded the adherence in the BALANCE-ICU pilot RCT (125/134, 93% vs 89/115, 77%, p = 0.0003). BALANCE-Ward patients were older, with lower Sequential Organ Failure Assessment scores, and higher proportions of infections caused by Escherichia coli and genito-urinary sources of bloodstream infection. The BALANCE-Ward pilot RCT patients had an overall 90-day mortality rate of 17/133 (12.8%), which was comparable to the 90-day mortality rate in the ICU pilot RCT (17/115, 14.8%) (p = 0.65). Simulation models indicated there would be minimal sample size and non-inferiority margin implications of expanding enrolment to increasing proportions of non-ICU versus ICU patients. CONCLUSION It is feasible to enroll non-ICU patients in a trial of 7 versus 14 days of antibiotics for bloodstream infection, and expanding the BALANCE RCT hospital-wide has the potential to improve the timeliness and generalizability of trial results. TRIAL REGISTRATION Clinicaltrials.gov, NCT02917551. Registered on September 28, 2016.
Collapse
Affiliation(s)
- Nick Daneman
- Division of Infectious Diseases & Clinical Epidemiology, Department of Medicine Sunnybrook Health Sciences Centre, University of Toronto and Adjunct Scientist, Institute for Clinical Evaluative Sciences, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada.
| | - Asgar H Rishu
- Department of Critical Care Medicine, Sunnybrook Health Sciences Center, Toronto, ON, Canada
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Center, Toronto, ON, Canada
| | - Yaseen Arabi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Intensive Care Department, Ministry of National Guard Health Affairs, Riyadh, Kingdom of Saudi Arabia
| | - Emilie P Belley-Cote
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Robert Cirone
- Division of Critical Care, St. Joseph's Health Centre, Toronto, ON, Canada
| | - Mark Downing
- Division of Infectious Diseases, St. Joseph's Health Centre, Toronto, ON, Canada
| | - Deborah J Cook
- Division of Critical Care Medicine, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Richard Hall
- Departments of Critical Care Medicine and Anesthesiology, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, NS, Canada
| | - Shay McGuinness
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
| | - Lauralyn McIntyre
- Division of Critical Care, Department of Medicine, The Ottawa Hospital, Ottawa, ON, Canada
| | - John Muscedere
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - Rachael Parke
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand.,The University of Auckland, Auckland, New Zealand
| | - Steven Reynolds
- Department of Biophysiology and Kinesiology, Simon Fraser University, Burnaby, BC, Canada
| | - Benjamin A Rogers
- Centre for Inflammatory Diseases, Monash University School of Clinical Sciences, Clayton, Victoria, Australia; Monash Infectious Diseases, Monash Health, Clayton, VIC, Australia
| | - Yahya Shehabi
- Critical Care and Perioperative Medicine, School of Clinical Sciences, Monash University and Monash Health, Clayton, Victoria, Australia and the Clinical School of Medicine, University of New South Wales, Randwick, NSW, Australia
| | - Phillip Shin
- Department of Medicine and Critical Care, North York General Hospital, Toronto, ON, Canada
| | - Richard Whitlock
- Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Robert A Fowler
- Departments of Medicine and Critical Care Medicine, Sunnybrook Health Sciences Center, Adjunct Scientist, Institute for Clinical Evaluative Sciences, Institute of Health Policy, Management and Evaluation, University of Toronto, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada.
| | | |
Collapse
|
32
|
Mendis N, Hamilton GM, McIsaac DI, Fergusson DA, Wunsch H, Dubois D, Montroy J, Chassé M, Turgeon AF, McIntyre L, McDonald H, Yang H, Sampson SD, McCartney CJL, Shorr R, Denault A, Lalu MM. A Systematic Review of the Impact of Surgical Special Care Units on Patient Outcomes and Health Care Resource Utilization. Anesth Analg 2019; 128:533-542. [PMID: 30676348 DOI: 10.1213/ane.0000000000003942] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Perioperative intermediate care units (termed surgical special care units) have been widely implemented across health systems because they are believed to improve surveillance and management of high-risk surgical patients. Our objective was to conduct a systematic review to investigate the effects of a 3-level model of perioperative care delivery (ie, ward, surgical special care unit, or intensive care unit) compared to a 2-level model of care (ie, ward, intensive care unit) on postoperative outcomes. Our protocol was registered with PROSPERO, the international prospective register of systematic reviews (CRD42015025155). Randomized controlled studies and nonrandomized comparator studies were included. We performed a systematic search of Medline, Cumulative Index to Nursing and Allied Health Literature, Embase, and the Cochrane library (inception - 11/2017). The primary outcome was mortality; secondary outcomes included length of stay and hospital costs. We identified 1995 citations with our search, and 21 studies met eligibility criteria (2 randomized controlled studies and 19 nonrandomized comparator studies; 44,134 patients in total). Surgical special care units were characterized by continuous monitoring (12 studies), the absence of mechanical ventilation (8 studies), nurse-to-patient ratios (range, 1:2-1:4), and number of beds (median: 5; range: 3-33). Thirteen studies reported on mortality. Notable findings included no observed difference in overall in-hospital mortality, but an apparent increase in intensive care unit mortality in a 3-level model of care. This may reflect a decanting of lower acuity patients from the intensive care unit to the surgical special care unit. No significant difference was found in hospital length of stay; however, 2 studies demonstrated reductions in hospital costs with the implementation of a surgical special care unit. Significant clinical and methodological heterogeneity precluded pooled analysis. Given the prevalence of surgical special care units, the results of our review suggest that additional methodologically rigorous investigations are needed to understand the effect of these units on the surgical population.
Collapse
Affiliation(s)
- Nicholas Mendis
- From the Department of Anesthesiology and Pain Medicine, The Ottawa Hospital and the University of Ottawa, Ottawa, Ontario, Canada
| | - Gavin M Hamilton
- From the Department of Anesthesiology and Pain Medicine, The Ottawa Hospital and the University of Ottawa, Ottawa, Ontario, Canada
| | - Daniel I McIsaac
- From the Department of Anesthesiology and Pain Medicine, The Ottawa Hospital and the University of Ottawa, Ottawa, Ontario, Canada.,Department of Epidemiology and Public Health, Ottawa Hospital Research Institute
| | - Dean A Fergusson
- Department of Epidemiology and Public Health, Ottawa Hospital Research Institute.,Clinical Epidemiology Program, Blueprint Translational Research Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Medicine, Surgery & Epidemiology and Department of Community Medicine, The University of Ottawa, Ottawa, Ontario, Canada
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Daniel Dubois
- From the Department of Anesthesiology and Pain Medicine, The Ottawa Hospital and the University of Ottawa, Ottawa, Ontario, Canada
| | - Joshua Montroy
- Department of Epidemiology and Public Health, Ottawa Hospital Research Institute.,Clinical Epidemiology Program, Blueprint Translational Research Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Michaël Chassé
- Department of Medicine (Critical Care), University of Montreal Hospital
| | - Alexis F Turgeon
- Department of Anesthesia and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, and CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit, Traumatology-Emergency-Critical Care Medicine, Université Laval, Québec, Quebec, Canada
| | - Lauralyn McIntyre
- Department of Epidemiology and Public Health, Ottawa Hospital Research Institute.,Department of Critical Care, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Heather McDonald
- Department of Anesthesia, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Homer Yang
- From the Department of Anesthesiology and Pain Medicine, The Ottawa Hospital and the University of Ottawa, Ottawa, Ontario, Canada
| | - Sonia D Sampson
- Department of Anesthesia, Memorial University of Newfoundland, St John's, Newfoundland, Canada
| | - Colin J L McCartney
- From the Department of Anesthesiology and Pain Medicine, The Ottawa Hospital and the University of Ottawa, Ottawa, Ontario, Canada.,Department of Epidemiology and Public Health, Ottawa Hospital Research Institute
| | - Risa Shorr
- Learning Services, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - André Denault
- Departments of Anesthesia and Critical Care, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Manoj M Lalu
- From the Department of Anesthesiology and Pain Medicine, The Ottawa Hospital and the University of Ottawa, Ottawa, Ontario, Canada.,Department of Epidemiology and Public Health, Ottawa Hospital Research Institute.,Clinical Epidemiology Program, Blueprint Translational Research Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Regenerative Medicine Program, Ottawa Hospital Research Institute, Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | |
Collapse
|
33
|
Gershkovich B, English SW, Doyle MA, Menon K, McIntyre L. Choice of crystalloid fluid in the treatment of hyperglycemic emergencies: a systematic review protocol. Syst Rev 2019; 8:228. [PMID: 31481108 PMCID: PMC6720374 DOI: 10.1186/s13643-019-1130-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 08/13/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are life-threatening complications of diabetes mellitus which require prompt treatment with large volume crystalloid fluid administration. A variety of crystalloid fluids is currently available for use and differs in their composition and ion concentrations. While there are potential pros and cons for different crystalloid fluids, it remains unknown if any particular fluid confers a clinical outcome benefit over others in the treatment of hyperglycemic emergencies. METHODS A systematic search of MEDLINE, Embase, and the Cochrane Library of Systematic Reviews will be conducted to identify eligible studies, which will include observational and interventional studies involving adult and pediatric patients admitted to the hospital with either DKA or HHS. The interventions will include intravenous treatment with 0.9% saline versus other buffered (Ringer's lactate, Hartmann's, etc.), and non-buffered (0.45% saline) crystalloid fluids. The primary outcome is mortality at the latest follow-up time point. Secondary outcomes will include mortality at specific time points, length of hospital stay, development of acute kidney injury, requirement for renal replacement therapy, altered level of consciousness, and the time to normalization of several serum biochemical parameters. Where appropriate, meta-analyses will be performed for the outcomes and conducted separately for adult and pediatric patient populations. DISCUSSION DKA and HHS are dangerous complications of diabetes mellitus and account for significant morbidity and mortality. Given the importance of crystalloid fluid administration in the management of these conditions, a systematic synthesis of the existing evidence base will identify potential evidence gaps and may help guide future clinical practice.
Collapse
Affiliation(s)
- Benjamin Gershkovich
- Department of Medicine, University of Ottawa, 401 Smyth Road, Ottawa, Ontario K1H 5B2 Canada
| | - Shane W. English
- Department of Medicine, University of Ottawa, 401 Smyth Road, Ottawa, Ontario K1H 5B2 Canada
- Clinical Epidemiology Program (CEP), Ottawa Hospital Research Institute, 401 Smyth Road, Ottawa, Ontario K1H 5B2 Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario Canada
| | - Mary-Anne Doyle
- Department of Medicine, University of Ottawa, 401 Smyth Road, Ottawa, Ontario K1H 5B2 Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario Canada
| | - Kusum Menon
- CHEO Research Institute, Ottawa, Ontario Canada
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario Canada
| | - Lauralyn McIntyre
- Department of Medicine, University of Ottawa, 401 Smyth Road, Ottawa, Ontario K1H 5B2 Canada
- Clinical Epidemiology Program (CEP), Ottawa Hospital Research Institute, 401 Smyth Road, Ottawa, Ontario K1H 5B2 Canada
| |
Collapse
|
34
|
Lehr AR, Rached-d’Astous S, Parker M, McIntyre L, Sampson M, Hamid J, Menon K. Impact of balanced versus unbalanced fluid resuscitation on clinical outcomes in critically ill children: protocol for a systematic review and meta-analysis. Syst Rev 2019; 8:195. [PMID: 31383009 PMCID: PMC6683512 DOI: 10.1186/s13643-019-1109-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Accepted: 07/22/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Isotonic crystalloid fluid bolus therapy is used in critically ill children to restore or maintain hemodynamic stability. However, the ideal choice of crystalloid remains to be determined. The most easily available and most frequently used crystalloid is 0.9% saline, an unbalanced crystalloid, that has been associated with hyperchloremic metabolic acidosis and acute kidney injury (AKI). Balanced fluids such as Ringer's lactate (RL) were developed to be closer to the composition of serum. However, they are more expensive and less readily available than 0.9% saline. Few trials have found RL to be associated with more favorable outcomes, but pediatric data is limited and inconsistent. The objective of the present systematic review is to review existing literature to determine the effect of balanced versus unbalanced fluid bolus therapy on metabolic acidosis in critically ill children. METHODS Using the Preferred Reporting Items for Systematic Review and Meta-analysis Protocols (PRISMA-P) guidelines, we will conduct a systematic review to retrieve all controlled trials and observational studies comparing balanced and unbalanced resuscitative fluids in critically ill children from age 28 days to 18 years old in any resuscitation settings. Search strategy was developed in collaboration with an experienced clinical research librarian. The primary outcome is the incidence and/or time to resolution of metabolic acidosis. Secondary outcomes included the incidence of hyperchloremia, AKI, duration of renal replacement therapy, vasopressors, mechanical ventilation, total volume of rehydration needed per day, extracorporeal membrane oxygenation, and length of stay and mortality. Study screening, inclusion, data extraction, and assessment of risk of bias will be performed independently by two authors. We intend to perform a meta-analysis with studies that are compatible on the basis of population and outcomes. DISCUSSION Isotonic crystalloid fluid bolus therapy is a ubiquitous treatment in resuscitation of critically ill pediatric patients and yet there is no clear recommendation to support the choice of balanced versus unbalanced fluid. The present review will summarize current available data in the literature and assess whether recommendations can be generated regarding the choice of crystalloids or otherwise identify knowledge gaps which will open the door to a large-scale randomized controlled trial (RCT).
Collapse
Affiliation(s)
- Anab Rebecca Lehr
- Division of Critical Care, Department of Pediatrics, University of Ottawa, Children’s Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON K1H 8L1 Canada
| | - Soha Rached-d’Astous
- Division of Emergency Medicine, Department of Pediatrics, University of Toronto, Hospital for Sick Children, Toronto, ON Canada
| | - Melissa Parker
- Division of Emergency Medicine, Department of Pediatrics, University of Toronto, Hospital for Sick Children, Toronto, ON Canada
- Division of Critical Care, Department of Pediatrics, McMaster University, Hamilton, ON Canada
| | - Lauralyn McIntyre
- Division of Critical Care, Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON Canada
| | - Margaret Sampson
- Library Services, Children’s Hospital of Eastern Ontario, Ottawa, ON Canada
| | - Jemila Hamid
- Clinical Research Unit, Children’s Hospital of Eastern Ontario, Ottawa, ON Canada
| | - Kusum Menon
- Division of Critical Care, Department of Pediatrics, University of Ottawa, Children’s Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, ON K1H 8L1 Canada
| |
Collapse
|
35
|
Clark EG, McIntyre L, Ramsay T, Tinmouth A, Knoll G, Brown PA, Watpool I, Porteous R, Montroy K, Harris S, Kong J, Hiremath S. Saline versus albumin fluid for extracorporeal removal with slow low-efficiency dialysis (SAFER-SLED): study protocol for a pilot trial. Pilot Feasibility Stud 2019; 5:72. [PMID: 31161046 PMCID: PMC6542057 DOI: 10.1186/s40814-019-0460-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 05/21/2019] [Indexed: 12/23/2022] Open
Abstract
Background Critically ill patients frequently develop acute kidney injury that necessitates renal replacement therapy (RRT). At some centers, critically ill patients who are hemodynamically unstable and require RRT are treated with slow low-efficiency dialysis (SLED). Unfortunately, hypotension is a frequent complication that occurs during SLED treatments and may limit the recovery of kidney function. Hypotension may also limit the amount of fluid that can be removed by ultrafiltration with SLED. Fluid overload can be exacerbated as a consequence, and fluid overload is associated with increased mortality. Occasionally, intravenous albumin fluid is given to prevent or treat low blood pressure during SLED. The intent of doing so is to increase the colloid oncotic pressure in the circulation to draw in extravascular fluid, increase the blood pressure, and enable more aggressive fluid removal with ultrafiltration. Nonetheless, there is little evidence to support this practice and theoretical reasons why it may not be especially effective at augmenting fluid removal in critically ill patients. At the same time, albumin fluid is expensive. As such, we present a protocol for a study to assess the feasibility of a randomized controlled trial evaluating the use of albumin fluid versus saline in critically ill patients receiving SLED. Methods This study is a single-center, double-blind, and randomized controlled pilot trial with two parallel arms. It involves randomly assigning patients receiving SLED treatment in the ICU to receive either albumin (25%) boluses or normal saline fluid boluses (placebo) to prevent and treat low blood pressure. Discussion The results of this pilot trial will help with planning a larger trial comparing the efficacy of the interventions in achieving fluid removal in critically ill patients with AKI on SLED. They will establish whether enough participants would participate in a larger study and accept the study procedures. Trial registration This trial is registered on ClinicalTrials.gov Identifier NCT03665311, registered on September 11, 2018. Electronic supplementary material The online version of this article (10.1186/s40814-019-0460-3) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Edward G Clark
- 1Division of Nephrology, Department of Medicine, The Ottawa Hospital, Riverside Campus, 1967 Riverside Drive, Ottawa, ON K1H 7W9 Canada
| | - Lauralyn McIntyre
- 2Division of Critical Care, Department of Medicine, The Ottawa Hospital, 501 Smyth Road, Ottawa, ON K1H 8L6 Canada
| | - Tim Ramsay
- 3Ottawa Methods Centre, Ottawa Hospital Research Institute, 501 Smyth Road, Ottawa, ON K1H 8L6 Canada
| | - Alan Tinmouth
- 4Division of Hematology, Department of Medicine, The Ottawa Hospital, 501 Smyth Road, Ottawa, ON K1H 8L6 Canada
| | - Greg Knoll
- 1Division of Nephrology, Department of Medicine, The Ottawa Hospital, Riverside Campus, 1967 Riverside Drive, Ottawa, ON K1H 7W9 Canada
| | - Pierre-Antoine Brown
- 1Division of Nephrology, Department of Medicine, The Ottawa Hospital, Riverside Campus, 1967 Riverside Drive, Ottawa, ON K1H 7W9 Canada
| | - Irene Watpool
- 2Division of Critical Care, Department of Medicine, The Ottawa Hospital, 501 Smyth Road, Ottawa, ON K1H 8L6 Canada
| | - Rebecca Porteous
- 2Division of Critical Care, Department of Medicine, The Ottawa Hospital, 501 Smyth Road, Ottawa, ON K1H 8L6 Canada
| | - Kaitlyn Montroy
- 2Division of Critical Care, Department of Medicine, The Ottawa Hospital, 501 Smyth Road, Ottawa, ON K1H 8L6 Canada
| | - Sophie Harris
- 5University of Ottawa, 75 Laurier Avenue, Ottawa, ON K1N 6N5 Canada
| | - Jennifer Kong
- 1Division of Nephrology, Department of Medicine, The Ottawa Hospital, Riverside Campus, 1967 Riverside Drive, Ottawa, ON K1H 7W9 Canada
| | - Swapnil Hiremath
- 1Division of Nephrology, Department of Medicine, The Ottawa Hospital, Riverside Campus, 1967 Riverside Drive, Ottawa, ON K1H 7W9 Canada
| |
Collapse
|
36
|
Suen CM, Stewart DJ, Montroy J, Welsh C, Levac B, Wesch N, Zhai A, Fergusson D, McIntyre L, Lalu MM. Regenerative cell therapy for pulmonary arterial hypertension in animal models: a systematic review. Stem Cell Res Ther 2019; 10:75. [PMID: 30841915 PMCID: PMC6404277 DOI: 10.1186/s13287-019-1172-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 01/30/2019] [Accepted: 02/11/2019] [Indexed: 12/21/2022] Open
Abstract
Background Pulmonary arterial hypertension (PAH) is a rare disease characterized by widespread loss of the pulmonary microcirculation and elevated pulmonary arterial pressures leading to pathological right ventricular remodeling and ultimately right heart failure. Regenerative cell therapies could potentially restore the effective lung microcirculation and provide a curative therapy for PAH. The objective of this systematic review was to compare the efficacy of regenerative cell therapies in preclinical models of PAH. Methods A systematic search strategy was developed and executed. We included preclinical animal studies using regenerative cell therapy in experimental models of PAH. Primary outcomes were right ventricular systolic pressure (RVSP) and mean pulmonary arterial pressure (mPAP). The secondary outcome was right ventricle/left ventricle + septum weight ratio (RV/LV+S). Pooled effect sizes were undertaken using random effects inverse variance models. Risk of bias and publication bias were assessed. Results The systematic search yielded 1285 studies, of which 44 met eligibility criteria. Treatment with regenerative cell therapy was associated with decreased RVSP (SMD − 2.10; 95% CI − 2.59 to − 1.60), mPAP (SMD − 2.16; 95% CI − 2.97 to − 1.35), and RV/LV+S (SMD − 1.31, 95% CI − 1.64 to − 0.97). Subgroup analysis demonstrated that cell modification resulted in greater reduction in RVSP. The effects on RVSP and mPAP remained statistically significant even after adjustment for publication bias. The majority of studies had an unclear risk of bias. Conclusions Preclinical studies of regenerative cell therapy demonstrated efficacy in animal models of PAH; however, future studies should consider incorporating design elements to reduce the risk of bias. Systematic review registration Suen CM, Zhai A, Lalu MM, Welsh C, Levac BM, Fergusson D, McIntyre L and Stewart DJ. Efficacy and safety of regenerative cell therapy for pulmonary arterial hypertension in animal models: a preclinical systematic review protocol. Syst Rev. 2016;5:89. Trial registration CAMARADES-NC3Rs Preclinical Systematic Review & Meta-analysis Facility (SyRF). http://syrf.org.uk/protocols/. Syst Rev 5:89, 2016 Electronic supplementary material The online version of this article (10.1186/s13287-019-1172-6) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Colin M Suen
- Regenerative Medicine Program, The Ottawa Hospital Research Institute, 501 Smyth Road, PO Box 201B, Ottawa, ON, K1H 8L6, Canada.,Department of Cell and Molecular Medicine, University of Ottawa, Ottawa, Canada
| | - Duncan J Stewart
- Regenerative Medicine Program, The Ottawa Hospital Research Institute, 501 Smyth Road, PO Box 201B, Ottawa, ON, K1H 8L6, Canada.,Department of Cell and Molecular Medicine, University of Ottawa, Ottawa, Canada.,Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Joshua Montroy
- Clinical Epidemiology Program, Ottawa, Canada.,Blueprint Translational Research Group, The Ottawa Hospital Research Institute, Ottawa, Canada
| | | | - Brendan Levac
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Neil Wesch
- Clinical Epidemiology Program, Ottawa, Canada.,Blueprint Translational Research Group, The Ottawa Hospital Research Institute, Ottawa, Canada
| | - Alexander Zhai
- Regenerative Medicine Program, The Ottawa Hospital Research Institute, 501 Smyth Road, PO Box 201B, Ottawa, ON, K1H 8L6, Canada
| | - Dean Fergusson
- Clinical Epidemiology Program, Ottawa, Canada.,Blueprint Translational Research Group, The Ottawa Hospital Research Institute, Ottawa, Canada.,Department of Medicine, University of Ottawa, Ottawa, Canada.,Depatrment of Surgery, University of Ottawa, Ottawa, Canada.,Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Canada
| | - Lauralyn McIntyre
- Clinical Epidemiology Program, Ottawa, Canada.,Blueprint Translational Research Group, The Ottawa Hospital Research Institute, Ottawa, Canada
| | - Manoj M Lalu
- Regenerative Medicine Program, The Ottawa Hospital Research Institute, 501 Smyth Road, PO Box 201B, Ottawa, ON, K1H 8L6, Canada. .,Department of Cell and Molecular Medicine, University of Ottawa, Ottawa, Canada. .,Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, The Ottawa Hospital Research Institute, Ottawa, Canada. .,Clinical Epidemiology Program, Ottawa, Canada. .,Blueprint Translational Research Group, The Ottawa Hospital Research Institute, Ottawa, Canada.
| |
Collapse
|
37
|
Saigle V, Asad S, Presseau J, Chassé M, McIntyre L, English SW. Do patient-reported outcome measures for SAH include patient, family, and caregiver priorities? A scoping review. Neurology 2019; 92:281-295. [PMID: 30626652 DOI: 10.1212/wnl.0000000000006883] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 10/03/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To systematically describe literature that identified patient/family/caregiver priorities for subarachnoid hemorrhage (SAH)-specific patient-reported outcome measures (PROMs), developed novel SAH PROMs by incorporating patient/family/caregiver perspectives, or involved patient/family/caregiver perspectives in evaluating existing SAH PROMs. METHODS We conducted a scoping review using Embase and Ovid MEDLINE from inception to February 6, 2018. Study eligibility and data extraction was performed independently and in duplicate. For each eligible citation, we abstracted information about study population, design, type of patient involvement, and outcome measures. We planned a descriptive summary of all included studies. RESULTS Our search yielded 4,961 citations, of which 15 met our eligibility criteria. Four of these included duplicate data, so our final sample consisted of 12 articles. There were 879 patients with SAH and 241 carers from the 11/12 articles that reported these data. One additional study involved 70 individuals but did not specify the number of carers or patients. We did not find any studies where SAH survivors or their families were directly involved in the full continuum of PROM outcome conceptualization from development to evaluation. We found 41 measures identified by patients with SAH. We identified only 2 PROMs developed with patients and only one that was a post hoc evaluation by patients. These 3 PROMs are subarachnoid hemorrhage outcome tool, Wessex Patient Carer Questionnaire, and Functional Status Examination, respectively. CONCLUSION We identified 3 PROMs that have involved patients in some way, but the extent to which they reflect patient priorities remains unclear. More work is needed to ensure SAH research is not overlooking outcomes that are important to patients.
Collapse
Affiliation(s)
- Victoria Saigle
- From the Clinical Epidemiology Program (Centre for Transfusion Research) (V.S., S.A., L.M., S.W.E.), Ottawa Hospital Research Institute (J.P.); School of Epidemiology and Public Health (J.P., S.W.E.) and Department of Medicine (Critical Care) (S.W.E., L.M.), University of Ottawa; and Department of Medicine (Critical Care) (M.C.), University of Montreal Hospital, Canada
| | - Sarah Asad
- From the Clinical Epidemiology Program (Centre for Transfusion Research) (V.S., S.A., L.M., S.W.E.), Ottawa Hospital Research Institute (J.P.); School of Epidemiology and Public Health (J.P., S.W.E.) and Department of Medicine (Critical Care) (S.W.E., L.M.), University of Ottawa; and Department of Medicine (Critical Care) (M.C.), University of Montreal Hospital, Canada
| | - Justin Presseau
- From the Clinical Epidemiology Program (Centre for Transfusion Research) (V.S., S.A., L.M., S.W.E.), Ottawa Hospital Research Institute (J.P.); School of Epidemiology and Public Health (J.P., S.W.E.) and Department of Medicine (Critical Care) (S.W.E., L.M.), University of Ottawa; and Department of Medicine (Critical Care) (M.C.), University of Montreal Hospital, Canada
| | - Michaël Chassé
- From the Clinical Epidemiology Program (Centre for Transfusion Research) (V.S., S.A., L.M., S.W.E.), Ottawa Hospital Research Institute (J.P.); School of Epidemiology and Public Health (J.P., S.W.E.) and Department of Medicine (Critical Care) (S.W.E., L.M.), University of Ottawa; and Department of Medicine (Critical Care) (M.C.), University of Montreal Hospital, Canada
| | - Lauralyn McIntyre
- From the Clinical Epidemiology Program (Centre for Transfusion Research) (V.S., S.A., L.M., S.W.E.), Ottawa Hospital Research Institute (J.P.); School of Epidemiology and Public Health (J.P., S.W.E.) and Department of Medicine (Critical Care) (S.W.E., L.M.), University of Ottawa; and Department of Medicine (Critical Care) (M.C.), University of Montreal Hospital, Canada
| | - Shane W English
- From the Clinical Epidemiology Program (Centre for Transfusion Research) (V.S., S.A., L.M., S.W.E.), Ottawa Hospital Research Institute (J.P.); School of Epidemiology and Public Health (J.P., S.W.E.) and Department of Medicine (Critical Care) (S.W.E., L.M.), University of Ottawa; and Department of Medicine (Critical Care) (M.C.), University of Montreal Hospital, Canada.
| |
Collapse
|
38
|
Nicholls SG, Carroll K, Brehaut J, Weijer C, Hey SP, Goldstein CE, Zwarenstein M, Graham ID, McKenzie JE, McIntyre L, Jairath V, Campbell MK, Grimshaw JM, Fergusson DA, Taljaard M. Stakeholder views regarding ethical issues in the design and conduct of pragmatic trials: study protocol. BMC Med Ethics 2018; 19:90. [PMID: 30458809 PMCID: PMC6247737 DOI: 10.1186/s12910-018-0332-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 11/08/2018] [Indexed: 12/31/2022] Open
Abstract
Background Randomized controlled trial (RCT) trial designs exist on an explanatory-pragmatic spectrum, depending on the degree to which a study aims to address a question of efficacy or effectiveness. As conceptualized by Schwartz and Lellouch in 1967, an explanatory approach to trial design emphasizes hypothesis testing about the mechanisms of action of treatments under ideal conditions (efficacy), whereas a pragmatic approach emphasizes testing effectiveness of two or more available treatments in real-world conditions. Interest in, and the number of, pragmatic trials has grown substantially in recent years, with increased recognition by funders and stakeholders worldwide of the need for credible evidence to inform clinical decision-making. This increase has been accompanied by the onset of learning healthcare systems, as well as an increasing focus on patient-oriented research. However, pragmatic trials have ethical challenges that have not yet been identified or adequately characterized. The present study aims to explore the views of key stakeholders with respect to ethical issues raised by the design and conduct of pragmatic trials. It is embedded within a large, four-year project that seeks to develop guidance for the ethical design and conduct of pragmatic trials. As a first step, this study will address important gaps in the current empirical literature with respect to identifying a comprehensive range of ethical issues arising from the design and conduct of pragmatic trials. By opening up a broad range of topics for consideration within our parallel ethical analysis, we will extend the current debate, which has largely emphasized issues of consent, to the range of ethical considerations that may flow from specific design choices. Methods Semi-structured interviews with key stakeholders (e.g. trialists, methodologists, lay members of study teams, bioethicists, and research ethics committee members), across multiple jurisdictions, identified based on their known experience and/or expertise with pragmatic trials. Discussion We expect that the study outputs will be of interest to a wide range of knowledge users including trialists, ethicists, research ethics committees, journal editors, regulators, healthcare policymakers, research funders and patient groups. All publications will adhere to the Tri-Agency Open Access Policy on Publications. Electronic supplementary material The online version of this article (10.1186/s12910-018-0332-z) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Stuart G Nicholls
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Civic Campus, 1053 Carling Avenue, Civic Box 693, Admin Services Building, ASB 2-013, Ottawa, ON, K1Y 4E9, Canada.
| | - Kelly Carroll
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Civic Campus, 1053 Carling Avenue, Civic Box 693, Admin Services Building, ASB 2-013, Ottawa, ON, K1Y 4E9, Canada
| | - Jamie Brehaut
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Civic Campus, 1053 Carling Avenue, Civic Box 693, Admin Services Building, ASB 2-013, Ottawa, ON, K1Y 4E9, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Charles Weijer
- Rotman Institute of Philosophy, Western University, London, ON, Canada
| | - Spencer Phillips Hey
- Center for Bioethics, Harvard Medical School, Boston, MA, USA.,Program on Regulation, Therapeutics and Law (PORTAL), Brigham and Women's Hospital, Boston, MA, USA
| | - Cory E Goldstein
- Rotman Institute of Philosophy, Western University, London, ON, Canada
| | - Merrick Zwarenstein
- Centre for Studies in Family Medicine, Department of Family Medicine, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Ian D Graham
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Civic Campus, 1053 Carling Avenue, Civic Box 693, Admin Services Building, ASB 2-013, Ottawa, ON, K1Y 4E9, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Joanne E McKenzie
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Lauralyn McIntyre
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Civic Campus, 1053 Carling Avenue, Civic Box 693, Admin Services Building, ASB 2-013, Ottawa, ON, K1Y 4E9, Canada
| | - Vipul Jairath
- Department of Medicine, Division of Gastroenterology, Western University, London, ON, Canada.,Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | | | - Jeremy M Grimshaw
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Civic Campus, 1053 Carling Avenue, Civic Box 693, Admin Services Building, ASB 2-013, Ottawa, ON, K1Y 4E9, Canada.,Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Civic Campus, 1053 Carling Avenue, Civic Box 693, Admin Services Building, ASB 2-013, Ottawa, ON, K1Y 4E9, Canada.,Faculty of Medicine, University of Ottawa, 501 Smyth Road, Box 201B, Ottawa, ON, K1H 8L6, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Civic Campus, 1053 Carling Avenue, Civic Box 693, Admin Services Building, ASB 2-013, Ottawa, ON, K1Y 4E9, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| |
Collapse
|
39
|
Al-Dorzi HM, Aldawood AS, Tamim H, Haddad SH, Jones G, McIntyre L, Solaiman O, Sakhija M, Sadat M, Afesh L, Kumar A, Bagshaw SM, Mehta S, M Arabi Y. Caloric intake and the fat-to-carbohydrate ratio in hypercapnic acute respiratory failure: Post-hoc analysis of the PermiT trial. Clin Nutr ESPEN 2018; 29:175-182. [PMID: 30661684 DOI: 10.1016/j.clnesp.2018.10.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 10/22/2018] [Indexed: 01/31/2023]
Abstract
BACKGROUND The effect of moderate caloric enteral intake in critically ill patients with hypercapnic acute respiratory failure (HCARF) is unclear. We studied the impact of permissive underfeeding (PUF) compared with standard feeding (SF) on various HCARF outcomes. MATERIALS AND METHODS The PermiT trial randomized 894 patients to either PUF (40-60% caloric requirement) or SF (70-100% requirement) with similar protein intake and found no difference in mortality, mechanical ventilation (MV) duration and ventilator-free days. In this post-hoc study, we restricted analysis to mechanically-ventilated patients with HCARF (PaCO2 >45 mmHg on the first two study days) and assessed the impact of trial interventions and fat-to-carbohydrate ratio on outcomes. RESULTS One-hundred-twenty patients had HCARF (59 PUF and 61 SF, age 53.7 ± 17.8 years, body mass index 31.1 ± 11.2 kg/m2, Acute Physiology and Chronic Health Evaluation II score 21.7 ± 7.1 and day-1 PaCO2 61 ± 16 mmHg). Caloric intake was 815 ± 270 kcal/day in PUF group and 1289 ± 407 kcal/day in SF group. The two groups had similar PaCO2 levels during ICU stay. The 90-day mortality (33.9% versus 35.6%, p = 0.85), MV duration (10.7 ± 6.8 versus 11.1 ± 8.1 days, p = 0.56) and ventilator-free days (52.9 ± 38.6 versus 51.2 ± 38.0 days, p = 0.80) were also similar in PUF and SF groups, respectively. Ventilator-free days and 90-day mortality were similar when the fat-to-carbohydrate ratio was < or ≥ the median value (0.73) in all patients and in PUF and SF groups. CONCLUSIONS In patients with HCARF, SF and PUF were associated with similar PaCO2, MV duration, ventilator-free days and mortality. Fat-to-carbohydrate ratio was not associated with mortality or ventilator-free days. TRIAL REGISTRATION ISRCTN Registry: ISRCTN68144998.
Collapse
Affiliation(s)
- Hasan M Al-Dorzi
- Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
| | - Abdulaziz S Aldawood
- Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
| | - Hani Tamim
- King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia; Department of Internal Medicine, American University of Beirut- Medical Center, Beirut, Lebanon.
| | - Samir H Haddad
- Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
| | - Gwynne Jones
- Department of Medicine, Division of Critical Care Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada.
| | - Lauralyn McIntyre
- Department of Medicine, Division of Critical Care Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada.
| | - Othman Solaiman
- Department of Adult Critical Care, King Faisal Specialist Hospital and Research Center, Riyadh 11426, Saudi Arabia.
| | - Maram Sakhija
- Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
| | - Musharaf Sadat
- Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
| | - Lara Afesh
- King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.
| | | | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada.
| | - Sangeeta Mehta
- Department of Medicine and Interdepartmental Division of Critical Care Medicine, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada.
| | - Yaseen M Arabi
- Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
| |
Collapse
|
40
|
Arabi YM, Al-Dorzi HM, Mehta S, Tamim HM, Haddad SH, Jones G, McIntyre L, Solaiman O, Sakkijha MH, Sadat M, Afesh L, Kumar A, Bagshaw SM, Aldawood AS. Association of protein intake with the outcomes of critically ill patients: a post hoc analysis of the PermiT trial. Am J Clin Nutr 2018; 108:988-996. [PMID: 30475959 DOI: 10.1093/ajcn/nqy189] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 07/26/2018] [Indexed: 12/12/2022] Open
Abstract
Background The optimal amount of protein intake in critically ill patients is uncertain. Objective In this post hoc analysis of the PermiT (Permissive Underfeeding vs. Target Enteral Feeding in Adult Critically Ill Patients) trial, we tested the hypothesis that higher total protein intake was associated with lower 90-d mortality and improved protein biomarkers in critically ill patients. Design In this post hoc analysis of the PermiT trial, we included patients who received enteral feeding for ≥3 consecutive days. Using the median protein intake of the cohort as a cutoff, patients were categorized into 2 groups: a higher-protein group (>0.80 g · kg-1 · d-1) and a lower-protein group (≤0.80 g · kg-1 · d-1). We developed a propensity score for receiving higher protein. Primary outcome was 90-d mortality. We also compared serial values of prealbumin, transferrin, 24-h urinary nitrogen, and 24-h nitrogen balance on days 1, 7, and 14. Results Among the 729 patients included in this analysis, the average protein intake was 0.8 ± 0.3 g · kg-1 · d-1 [1.0 ± 0.2 g · kg-1 · d-1 in the higher-protein group (n = 365) and 0.6 ± 0.2 g · kg-1 · d-1 in the lower-protein group (n = 364); P < 0.0001]. There was no difference in 90-d mortality between the 2 groups [88/364 (24.2%) compared with 94/363 (25.9%), propensity score-adjusted OR: 0.80; 95% CI: 0.56, 1.16; P = 0.24]. Higher protein intake was associated with an increase in 24-h urea nitrogen excretion compared with lower protein intake, but without a significant change in prealbumin, transferrin, or 24-h nitrogen balance. Conclusions In the PermiT trial, a moderate difference in protein intake was not associated with lower mortality. Higher protein intake was associated with increased nitrogen excretion in the urine without a corresponding change in prealbumin, transferrin, or nitrogen balance. Protein intake needs to be tested in adequately powered randomized controlled trials targeting larger differences in protein intake in high-risk populations.
Collapse
Affiliation(s)
- Y M Arabi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center.,Intensive Care Department, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia
| | - H M Al-Dorzi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center.,Intensive Care Department, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia
| | - S Mehta
- Department of Medicine and Interdepartmental Division of Critical Care Medicine, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada
| | - H M Tamim
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center.,Intensive Care Department, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia.,Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - S H Haddad
- Intensive Care Department, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia
| | - G Jones
- Department of Medicine, Division of Critical Care Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada
| | - L McIntyre
- Department of Medicine, Division of Critical Care Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada
| | - O Solaiman
- King Faisal Specialist Hospital and Research Center, Riyadh, Kingdom of Saudi Arabia
| | - M H Sakkijha
- Intensive Care Department, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia
| | - M Sadat
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center.,Intensive Care Department, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia
| | - L Afesh
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center.,Intensive Care Department, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia
| | - A Kumar
- Health Sciences Center, Manitoba, Canada
| | - S M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - A S Aldawood
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center.,Intensive Care Department, King Abdulaziz Medical City, Riyadh, Kingdom of Saudi Arabia
| | | |
Collapse
|
41
|
Taljaard M, Weijer C, Grimshaw JM, Ali A, Brehaut JC, Campbell MK, Carroll K, Edwards S, Eldridge S, Forrest CB, Giraudeau B, Goldstein CE, Graham ID, Hemming K, Hey SP, Horn AR, Jairath V, Klassen TP, London AJ, Marlin S, Marshall JC, McIntyre L, McKenzie JE, Nicholls SG, Alison Paprica P, Zwarenstein M, Fergusson DA. Developing a framework for the ethical design and conduct of pragmatic trials in healthcare: a mixed methods research protocol. Trials 2018; 19:525. [PMID: 30261933 PMCID: PMC6161426 DOI: 10.1186/s13063-018-2895-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 08/31/2018] [Indexed: 01/03/2023] Open
Abstract
Background There is a widely recognized need for more pragmatic trials that evaluate interventions in real-world settings to inform decision-making by patients, providers, and health system leaders. Increasing availability of electronic health records, centralized research ethics review, and novel trial designs, combined with support and resources from governments worldwide for patient-centered research, have created an unprecedented opportunity to advance the conduct of pragmatic trials, which can ultimately improve patient health and health system outcomes. Such trials raise ethical issues that have not yet been fully addressed, with existing literature concentrating on regulations in specific jurisdictions rather than arguments grounded in ethical principles. Proposed solutions (e.g. using different regulations in “learning healthcare systems”) are speculative with no guarantee of improvement over existing oversight procedures. Most importantly, the literature does not reflect a broad vision of protecting the core liberty and welfare interests of research participants. Novel ethical guidance is required. We have assembled a team of ethicists, trialists, methodologists, social scientists, knowledge users, and community members with the goal of developing guidance for the ethical design and conduct of pragmatic trials. Methods Our project will combine empirical and conceptual work and a consensus development process. Empirical work will: (1) identify a comprehensive list of ethical issues through interviews with a small group of key informants (e.g. trialists, ethicists, chairs of research ethics committees); (2) document current practices by reviewing a random sample of pragmatic trials and surveying authors; (3) elicit views of chairs of research ethics committees through surveys in Canada, UK, USA, France, and Australia; and (4) elicit views and experiences of community members and health system leaders through focus groups and surveys. Conceptual work will consist of an ethical analysis of identified issues and the development of new ethical solutions, outlining principles, policy options, and rationales. The consensus development process will involve an independent expert panel to develop a final guidance document. Discussion Planned output includes manuscripts, educational materials, and tailored guidance documents to inform and support researchers, research ethics committees, journal editors, regulators, and funders in the ethical design and conduct of pragmatic trials.
Collapse
Affiliation(s)
- Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), The Ottawa Hospital, Civic Campus, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada. .,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.
| | - Charles Weijer
- Rotman Institute of Philosophy, Western University, 1151 Richmond Street, London, ON, N6A 5B7, Canada
| | - Jeremy M Grimshaw
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), The Ottawa Hospital, General Campus, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada.,Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Adnan Ali
- Patient and Family Advisory Council, The Ottawa Hospital, Ottawa, ON, Canada
| | - Jamie C Brehaut
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), The Ottawa Hospital, General Campus, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
| | - Marion K Campbell
- Health Services Research Unit, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, AB25 2ZD, UK
| | - Kelly Carroll
- Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), The Ottawa Hospital, General Campus, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
| | - Sarah Edwards
- Department of Science and Technology Studies, University College London, 22 Gordon Square, King's Cross, London, WC1H 0AW, UK
| | - Sandra Eldridge
- Centre for Primary Care and Public Health, Queen Mary University of London, 58 Turner Street, London, E1 2AB, UK
| | - Christopher B Forrest
- Applied Clinical Research Center, Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA, 19146, USA
| | - Bruno Giraudeau
- Université de Tours, Université de Nantes, INSERM, SPHERE U1246, Tours, France.,INSERM CIC1415, CHRU de Tours, Tours, France
| | - Cory E Goldstein
- Rotman Institute of Philosophy, Western University, 1151 Richmond Street, London, ON, N6A 5B7, Canada
| | - Ian D Graham
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), The Ottawa Hospital, General Campus, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
| | - Karla Hemming
- Institute of Applied Health Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - Spencer Phillips Hey
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, 1620 Tremont Street, Boston, MA, 02120, USA.,Center for Bioethics, Harvard Medical School, Boston, MA, USA
| | - Austin R Horn
- Rotman Institute of Philosophy, Western University, 1151 Richmond Street, London, ON, N6A 5B7, Canada
| | - Vipul Jairath
- Division of Gastroenterology, Department of Medicine, Western University, London, ON, Canada.,Division of Epidemiology and Biostatistics, Western University, University Hospital, 339 Windermere Road, London, ON, N6A 5A5, Canada
| | - Terry P Klassen
- Children's Hospital Research Institute of Manitoba, 513-715 McDermot Avenue, Winnipeg, MB, R3E 3P, Canada
| | - Alex John London
- Department of Philosophy and Center for Ethics and Policy, Carnegie Mellon University, 150A Baker Hall, Pittsburgh, PA, 15213-3890, USA
| | - Susan Marlin
- Clinical Trials Ontario, 661 University Avenue, MaRS Centre, West Tower, Toronto, ON, M5G 1M1, Canada
| | - John C Marshall
- St. Michael's Hospital, Department of Surgery, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Lauralyn McIntyre
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), The Ottawa Hospital, General Campus, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada.,Department of Medicine (Division of Critical Care), University of Ottawa, Ottawa, ON, Canada
| | - Joanne E McKenzie
- School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Stuart G Nicholls
- Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), The Ottawa Hospital, Civic Campus, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada
| | - P Alison Paprica
- Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, 155 College Street, Toronto, ON, M5T 3M6, Canada
| | - Merrick Zwarenstein
- Centre for Studies in Family Medicine, Department of Family Medicine Schulich School of Medicine & Dentistry Western University, 1151 Richmond Street, London, ON, N6A 3K7, Canada
| | - Dean A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute (OHRI), The Ottawa Hospital, Civic Campus, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.,Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| |
Collapse
|
42
|
Lalu MM, Mazzarello S, Zlepnig J, Dong YYR, Montroy J, McIntyre L, Devereaux PJ, Stewart DJ, David Mazer C, Barron CC, McIsaac DI, Fergusson DA. Safety and Efficacy of Adult Stem Cell Therapy for Acute Myocardial Infarction and Ischemic Heart Failure (SafeCell Heart): A Systematic Review and Meta-Analysis. Stem Cells Transl Med 2018; 7:857-866. [PMID: 30255989 PMCID: PMC6265630 DOI: 10.1002/sctm.18-0120] [Citation(s) in RCA: 82] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 07/02/2018] [Indexed: 12/25/2022] Open
Abstract
Preclinical and clinical evidence suggests that mesenchymal stem cells (MSCs) may be beneficial in treating both acute myocardial infarction (AMI) and ischemic heart failure (IHF). However, the safety profile and efficacy of MSC therapy is not well‐known. We conducted a systematic review of clinical trials that evaluated the safety or efficacy of MSCs for AMI or IHF. Embase, PubMed/Medline, and Cochrane Central Register of Controlled Trials were searched from inception to September 27, 2017. Studies that examined the use of MSCs administered to adults with AMI or IHF were eligible. The Cochrane risk of bias tool was used to assess bias of included studies. The primary outcome was safety assessed by adverse events and the secondary outcome was efficacy which was assessed by mortality and left ventricular ejection fraction (LVEF). A total of 668 citations were reviewed and 23 studies met eligibility criteria. Of these, 11 studies evaluated AMI and 12 studies evaluated IHF. There was no association between MSCs and acute adverse events. There was a significant improvement in overall LVEF in patients who received MSCs (SMD 0.73, 95% CI 0.24–1.21). No significant difference in mortality was noted (Peto OR 0.68, 95% CI 0.38–1.22). Results from our systematic review suggest that MSC therapy for ischemic heart disease appears to be safe. There is a need for a well‐designed adequately powered randomized control trial (with rigorous adverse event reporting and evaluations of cardiac function) to further establish a clear risk‐benefit profile of MSCs. Stem Cells Translational Medicine2018;7:857–866
Collapse
Affiliation(s)
- Manoj M Lalu
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada.,Blueprint Translational Research Group, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Regenerative Medicine Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sasha Mazzarello
- Blueprint Translational Research Group, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Jennifer Zlepnig
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Joshua Montroy
- Blueprint Translational Research Group, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Lauralyn McIntyre
- Blueprint Translational Research Group, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Division of Critical Care, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - P J Devereaux
- Population Health Research Institute, David Braley Cardiac, Vascular, and Stroke Research Institute, Departments of Medicine and Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Duncan J Stewart
- Regenerative Medicine Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Cellular and Molecular Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - C David Mazer
- Department of Anesthesia, Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Department of Physiology, Toronto, Ontario, Canada
| | - Carly C Barron
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Daniel I McIsaac
- Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, Ottawa, Ontario, Canada.,Blueprint Translational Research Group, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Dean A Fergusson
- Blueprint Translational Research Group, Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| |
Collapse
|
43
|
English SW, McIntyre L, Saigle V, Chassé M, Fergusson DA, Turgeon AF, Lauzier F, Griesdale D, Garland A, Zarychanski R, Algird A, van Walraven C. The Ottawa SAH search algorithms: protocol for a multi- centre validation study of primary subarachnoid hemorrhage prediction models using health administrative data (the SAHepi prediction study protocol). BMC Med Res Methodol 2018; 18:94. [PMID: 30219029 PMCID: PMC6139177 DOI: 10.1186/s12874-018-0553-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Accepted: 08/31/2018] [Indexed: 01/07/2023] Open
Abstract
Background Conducting prospective epidemiological studies of hospitalized patients with rare diseases like primary subarachnoid hemorrhage (pSAH) are difficult due to time and budgetary constraints. Routinely collected administrative data could remove these barriers. We derived and validated 3 algorithms to identify hospitalized patients with a high probability of pSAH using administrative data. We aim to externally validate their performance in four hospitals across Canada. Methods Eligible patients include those ≥18 years of age admitted to these centres from January 1, 2012 to December 31, 2013. We will include patients whose discharge abstracts contain predictive variables identified in the models (ICD-10-CA diagnostic codes I60** (subarachnoid hemorrhage), I61** (intracranial hemorrhage), 162** (other nontrauma intracranial hemorrhage), I67** (other cerebrovascular disease), S06** (intracranial injury), G97 (other postprocedural nervous system disorder) and CCI procedural codes 1JW51 (occlusion of intracranial vessels), 1JE51 (carotid artery inclusion), 3JW10 (intracranial vessel imaging), 3FY20 (CT scan (soft tissue of neck)), and 3OT20 (CT scan (abdominal cavity)). The algorithms will be applied to each patient and the diagnosis confirmed via chart review. We will assess each model’s sensitivity, specificity, negative and positive predictive value across the sites. Discussion Validating the Ottawa SAH Prediction Algorithms will provide a way to accurately identify large SAH cohorts, thereby furthering research and altering care.
Collapse
Affiliation(s)
- S W English
- Department of Medicine (Critical Care), University of Ottawa, Ottawa, ON, K1Y 4E9, Canada. .,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | - L McIntyre
- Department of Medicine (Critical Care), University of Ottawa, Ottawa, ON, K1Y 4E9, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - V Saigle
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - M Chassé
- Department of Medicine, Division of Critical Care, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - D A Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - A F Turgeon
- Centre de recherche du CHU de Québec, Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), Université Laval, Québec City, QC, Canada.,Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, QC, Canada
| | - F Lauzier
- Centre de recherche du CHU de Québec, Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), Université Laval, Québec City, QC, Canada.,Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City, QC, Canada.,Centre de recherche du Centre Hospitalier de l'Université de Québec, Université Laval, Québec City, QC, Canada
| | - D Griesdale
- Deparment of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, Canada
| | - A Garland
- Department of Internal Medicine, Sections of Critical Care and Respirology, University of Manitoba, Winnipeg, MB, Canada
| | - R Zarychanski
- Department of Internal Medicine, Sections of Critical Care and Hematology/Medical Oncology, University of Manitoba, Winnipeg, MB, Canada
| | - A Algird
- Department of Neurosurgy, McMaster University, Hamilton Health Sciences, Hamilton, ON, Canada
| | - C van Walraven
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Department of Medicine, University of Ottawa, Ottawa, Canada
| |
Collapse
|
44
|
McIntyre L, Taljaard M, McArdle T, Fox-Robichaud A, English SW, Martin C, Marshall J, Menon K, Muscedere J, Cook DJ, Weijer C, Saginur R, Maybee A, Iyengar A, Forster A, Graham ID, Hawken S, McCartney C, Seely AJE, Stiell IG, Thavorn K, Fergusson DA. FLUID trial: a protocol for a hospital-wide open-label cluster crossover pragmatic comparative effectiveness randomised pilot trial. BMJ Open 2018; 8:e022780. [PMID: 30139908 PMCID: PMC6112401 DOI: 10.1136/bmjopen-2018-022780] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION 0.9% saline and Ringer's lactate are the two most common resuscitation crystalloid fluids. 0.9% saline may lead to hyperchloraemic metabolic acidosis and may be associated with impaired kidney function and death. Few large multicentre randomised trials have been conducted to evaluate the effect of these two fluids on clinically important outcomes. METHODS FLUID is a pragmatic pilot cluster randomised crossover trial in which four hospitals will be randomised to normal saline or Ringer's lactate for 14 weeks, then crossover to the alternative fluid for the subsequent 14 weeks after 1 to 3 week transition. With waiver of informed consent, all adult and paediatric patients admitted to participating sites will be included in the FLUID trial except for neonates. Primary feasibility outcome is study fluid protocol adherence (target:≥80%). Secondary feasibility outcomes include time to research ethics board (REB) approval and readiness to trial initiation (≤3 months from REB submission and approval). Primary (composite of death or re-admission to hospital in first 90 days of index hospitalisation) and secondary clinical outcomes for the future large FLUID trial will be described. Protocol adherence will be collected by site at specified time points. All clinical data will be obtained at patient level through provincial health administrative data held at the Institute for Clinical Evaluative Sciences (ICES). Event rates for the primary and secondary outcomes will be described using frequencies and proportions with 95% CIs. Intracluster and interperiod correlation coefficients will be calculated from population-level data available at ICES. ETHICS AND DISSEMINATION The study protocol has been approved by the Ottawa Health Science Research Ethics Board. The FLUID pilot will determine feasibility, and ICES data across all potential sites in Ontario will allow calculation of sample size parameter estimates to inform the design and implementation of the large trial. TRIAL REGISTRATION NUMBER NCT02721485; Pre-results.
Collapse
Affiliation(s)
- Lauralyn McIntyre
- Department of Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, Division of Critical Care, University of Ottawa, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Monica Taljaard
- Department of Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Tracy McArdle
- Department of Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Alison Fox-Robichaud
- Department of Medicine, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Shane W English
- Department of Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, Division of Critical Care, University of Ottawa, Ottawa, Ontario, Canada
| | - Claudio Martin
- Division of Critical Care Medicine, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - John Marshall
- Department of Surgery, St Michael’s Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Kusum Menon
- Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - John Muscedere
- Department of Critical Care Medicine, Kingston General Hospital, Queen’s University, Kingston, Ontario, Canada
| | - Deborah J Cook
- Departments of Medicine, Clinical Epidemiology and Biostatistics, St Joseph’s Healthcare Hamilton, McMaster University, Hamilton, Ontario, Canada
| | - Charles Weijer
- Rotman Institute of Philosophy, Western University, London, Ontario, Canada
| | - Raphael Saginur
- Department of Medicine, The Ottawa Hospital (Infectious Diseases), University of Ottawa, Ottawa, Ontario, Canada
| | - Alies Maybee
- Patient Engagement Advisory Board, Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Akshai Iyengar
- The Queensway Carleton Hospital, Ottawa, Ontario, Canada
| | - Alan Forster
- Department of Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Ian D Graham
- Department of Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Steven Hawken
- Department of Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Colin McCartney
- Department of Anesthesiology, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Andrew JE Seely
- Department of Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Ian G Stiell
- Department of Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Kednapa Thavorn
- Department of Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Dean A Fergusson
- Department of Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| |
Collapse
|
45
|
Thompson M, McIntyre L, Hutton B, Tran A, Wolfe D, Hutchison J, Fergusson D, Turgeon AF, English SW. Comparison of crystalloid resuscitation fluids for treatment of acute brain injury: a clinical and pre-clinical systematic review and network meta-analysis protocol. Syst Rev 2018; 7:125. [PMID: 30115113 PMCID: PMC6097326 DOI: 10.1186/s13643-018-0790-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 07/30/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Current guidelines identify the choice of fluid resuscitation as important in minimizing the incidence of secondary brain injury from cerebral edema. It is widely accepted that isotonic crystalloid resuscitation fluids, specifically normal saline (NS), are optimal for resuscitation and that other relatively hypotonic fluids, such as Ringer's lactate (RL), should be avoided in this patient population. The aim of this review is to systematically compare the use of relatively hypotonic versus isotonic crystalloid resuscitation fluids in clinical and pre-clinical models of acute brain injury and their effect on outcomes. In recognition of the potential need for a network meta-analysis (NMA), we have also included all other relevant crystalloid resuscitation fluids as interventions of relevance to potentially inform indirect comparisons. METHODS Systematic searches of MEDLINE, Embase, and Web of Science BIOSIS Previews® will be used to identify eligible clinical and pre-clinical studies, which included studies examining acute brain injury (human and in vivo animal brain injury models) within the first 7 days of therapy. The intervention of interest is the intravenous use of relatively hypotonic crystalloid resuscitation fluids (e.g., Ringer's lactate, Hartmann's or Plasma Lyte® fluids). The main comparator of interest is an isotonic crystalloid resuscitation fluid, specifically normal saline (0.9%). Other crystalloid resuscitation fluids (e.g., hypertonic saline (3-23.4%)) will also be included as an additional intervention of interest. The primary outcome measures of interest are intracranial pressure (ICP) and cerebral perfusion pressure (CPP). Secondary outcomes include the effect of resuscitation on cerebral edema, brain and serum osmolarity, and electrolyte concentrations and clinical outcomes including modified Rankin Scale (mRS), (extended) Glasgow Outcome Scale (GOS/eGOS), and mortality. Separate meta-analyses will be conducted to quantify the effects of the different fluid resuscitation on acute brain injury outcomes in clinical and pre-clinical populations. Network meta-analyses to compare interventions will also be performed to compare the effects of different interventions. DISCUSSION This systematic review will comprehensively summarize the difference in treatment efficacy of various crystalloid resuscitation fluids in acute brain injury. This review is essential to underscore the evidence, or lack thereof, present in the literature to date to support current preference-driven practice and to direct future study. SYSTEMATIC REVIEW REGISTRATION PROSPERO #CRD42016042960.
Collapse
Affiliation(s)
- Mary Thompson
- Clinical Epidemiology Program (CEP), Ottawa Hospital Research Institute, Ottawa, Ontario Canada
| | - Lauralyn McIntyre
- Clinical Epidemiology Program (CEP), Ottawa Hospital Research Institute, Ottawa, Ontario Canada
- Department of Medicine (Critical Care), University of Ottawa, CPCR Building, 501 Smyth Rd, CPCR Box 201B, Ottawa, Ontario K1H 8L6 Canada
| | - Brian Hutton
- Clinical Epidemiology Program (CEP), Ottawa Hospital Research Institute, Ottawa, Ontario Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario Canada
| | - Alexandre Tran
- Department of General Surgery, University of Ottawa, Ottawa, Ontario Canada
| | - Dianna Wolfe
- Clinical Epidemiology Program (CEP), Ottawa Hospital Research Institute, Ottawa, Ontario Canada
| | - Jamie Hutchison
- Department of Critical Care, Sick Kids Hospital, Toronto, Ontario Canada
| | - Dean Fergusson
- Clinical Epidemiology Program (CEP), Ottawa Hospital Research Institute, Ottawa, Ontario Canada
| | - Alexis F. Turgeon
- Clinical Epidemiology Program (CEP), Ottawa Hospital Research Institute, Ottawa, Ontario Canada
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Quebec City, Quebec Canada
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Unit (Trauma - Emergency - Critical Care Medicine), CHU de Québec, Université Laval (Hôpital de L’Enfant-Jésus), Quebec City, Quebec Canada
| | - Shane W. English
- Clinical Epidemiology Program (CEP), Ottawa Hospital Research Institute, Ottawa, Ontario Canada
- Department of Medicine (Critical Care), University of Ottawa, CPCR Building, 501 Smyth Rd, CPCR Box 201B, Ottawa, Ontario K1H 8L6 Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario Canada
| |
Collapse
|
46
|
Menon K, McNally D, Acharya A, O'Hearn K, Choong K, Wong HR, McIntyre L, Lawson M. Random serum free cortisol and total cortisol measurements in pediatric septic shock. J Pediatr Endocrinol Metab 2018; 31:757-762. [PMID: 29953408 DOI: 10.1515/jpem-2018-0027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 04/23/2018] [Indexed: 11/15/2022]
Abstract
Background The aim of the study was to examine the relationship between serum total cortisol (TC) and free cortisol (FC) levels in children with septic shock and the relationship of these levels with baseline illness severity. Methods A sub-study of a randomized controlled trial (RCT) of hydrocortisone vs. placebo in pediatric septic shock conducted in seven academic pediatric intensive care units (PICUs) in Canada on children aged newborn to 17 years. Thirty children with septic shock had serum sent for TC and FC measurement within 6 h of meeting the study eligibility criteria. Results Baseline FC and TC levels were strongly correlated with baseline Pediatric Risk of Mortality (PRISM) score (R2=0.759, p<0.001; R2=0.717, p<0.001) and moderately correlated with admission Vasotropic Inotropic Score (VIS) (R2=0.489, p<0.001; R2=0.316, p<0.001). Serum TC levels were highly correlated with FC levels (R2=0.92, p<0.001) and showed strong agreement (R2=0.98, p<0.001 on a Bland-Altman plot). The ratio of FC to TC moderately correlated with TC levels (R2=0.46, p<0.001) but did not correlate with baseline albumin levels (R2=0.19, p=0.13). Conclusions Random TC and FC levels are strongly correlated, show strong agreement and are reflective of illness severity in children with septic shock. As such, isolated FC measurement does not appear to provide added information relative to TC in acutely ill children with septic shock.
Collapse
Affiliation(s)
- Kusum Menon
- Children's Hospital of Eastern Ontario, Department of Pediatrics, 401 Smyth Road, Ottawa, ON K1H 8L1, Canada, Phone: +6137377600 (2538), Fax: +6137384287
| | - Dayre McNally
- Children's Hospital of Eastern Ontario, Department of Pediatrics, Ottawa, ON, Canada
| | - Anand Acharya
- Carleton University, Department of Economics, Ottawa, ON, Canada
| | - Katharine O'Hearn
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada
| | - Karen Choong
- McMaster Children's Hospital, Department of Pediatrics, Hamilton, ON, Canada
| | - Hector R Wong
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Margaret Lawson
- Children's Hospital of Eastern Ontario, Department of Pediatrics, Ottawa, ON, Canada
| | | |
Collapse
|
47
|
English SW, Chassé M, Turgeon AF, Lauzier F, Griesdale D, Garland A, Fergusson D, Zarychanski R, van Walraven C, Montroy K, Ziegler J, Dupont-Chouinard R, Carignan R, Dhaliwal A, Mallick R, Sinclair J, Boutin A, Pagliarello G, Tinmouth A, McIntyre L. Anemia prevalence and incidence and red blood cell transfusion practices in aneurysmal subarachnoid hemorrhage: results of a multicenter cohort study. Crit Care 2018; 22:169. [PMID: 29973245 PMCID: PMC6031110 DOI: 10.1186/s13054-018-2089-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 06/07/2018] [Indexed: 11/16/2022]
Abstract
Background Whether a restrictive strategy for red blood cell (RBC) transfusion is applied to patients with aneurysmal subarachnoid hemorrhage (aSAH) is unclear. To inform the design and conduct of a future clinical trial, we sought to describe transfusion practices, hemoglobin (Hb) triggers, and predictors of RBC transfusion in patients with aSAH. Methods This is a retrospective cohort study of all consecutively admitted adult patients with aSAH at four tertiary care centers from January 1, 2012, to December 31, 2013. Patients were identified from hospital administrative discharge records and existing local aSAH databases. Data collection by trained abstractors included demographic data, aSAH characteristics, Hb and transfusion data, other major aSAH cointerventions, and outcomes using a pretested case report form with standardized procedures. Descriptive statistics were used to summarize data, and regression models were used to identify associations between anemia, transfusion, and other relevant predictors and outcome. Results A total of 527 patients met inclusion eligibility. Mean (±SD) age was 57 ± 13 years, and 357 patients (67.7%) were female. The median modified Fisher grade was 4 (IQR 3–4). Mean nadir Hb was 98 ± 20 g/L and occurred on median admission day 4 (IQR 2–11). RBC transfusion occurred in 100 patients (19.0%). Transfusion rates varied across centers (12.1–27.4%, p = 0.02). Patients received a median of 1 RBC unit (IQR 1–2) per transfusion episode and a median total of 2 units (IQR 1–4). Median pretransfusion Hb for first transfusion was 79 g/L (IQR 74–93) and did not vary substantially across centers (78–82 g/L, p = 0.37). Of patients with nadir Hb < 80 g/L, 66.3% received a transfusion compared with 2.0% with Hb nadir ≥ 100 g/L (p < 0.0001). Predictors of transfusion were history of oral anticoagulant use, anterior circulation aneurysm, neurosurgical clipping, and lower Hb. Controlling for numerous potential confounders, transfusion was not independently associated with poor outcome. Conclusions We observed that moderate anemia remains very common early in admission following SAH. Only one-fifth of patients with SAH received RBC transfusions, mostly in cases of significant anemia (Hb < 80 g/L), and this did not appear to be associated with outcome. Electronic supplementary material The online version of this article (10.1186/s13054-018-2089-7) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Shane W English
- Department of Medicine (Critical Care), The Ottawa Hospital, Civic Campus Room F202, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada. .,Clinical Epidemiology Program (Centre for Transfusion Research), Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | - Michaël Chassé
- Department of Medicine, University of Montreal, Montreal, QC, Canada
| | - Alexis F Turgeon
- Department of Anesthesiology & Critical Care, Université Laval, Quebec City, QC, Canada
| | - François Lauzier
- Department of Anesthesiology & Critical Care, Université Laval, Quebec City, QC, Canada.,Department of Medicine, Université Laval, Quebec City, QC, Canada
| | - Donald Griesdale
- Deparment of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Allan Garland
- Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Dean Fergusson
- Clinical Epidemiology Program (Centre for Transfusion Research), Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Ryan Zarychanski
- Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | | | - Kaitlyn Montroy
- Clinical Epidemiology Program (Centre for Transfusion Research), Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Jennifer Ziegler
- Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | | | - Raphaëlle Carignan
- Department of Anesthesiology & Critical Care, Université Laval, Quebec City, QC, Canada
| | - Andy Dhaliwal
- Department of Medicine, University of Saskatchewan, Regina, SK, Canada
| | - Ranjeeta Mallick
- Clinical Epidemiology Program (Centre for Transfusion Research), Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - John Sinclair
- Department of Surgery (Neurosurgery), University of Ottawa, Ottawa, ON, Canada
| | - Amélie Boutin
- Department of Social and Preventive Medicine, Université Laval, Quebec City, QC, Canada
| | | | - Alan Tinmouth
- Clinical Epidemiology Program (Centre for Transfusion Research), Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Lauralyn McIntyre
- Department of Medicine (Critical Care), The Ottawa Hospital, Civic Campus Room F202, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada.,Clinical Epidemiology Program (Centre for Transfusion Research), Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | |
Collapse
|
48
|
Thomspon M, Wolfe D, Champagne J, Mei S, Lalu M, Fergusson D, Winston B, Marshall J, Walley K, English S, dos Santos C, Granton J, Stewart D, McIntyre L. Safety of cell therapy with mesenchymal stromal cells): An updated systematic review and meta-analysis of randomized controlled trials (SafeCell update). Cytotherapy 2018. [DOI: 10.1016/j.jcyt.2018.02.146] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
49
|
Salkhordeh M, Tan Y, McIntyre L, Stewart D, Mei S. Evaluation of different cryopreservation agents for mesenchymal stem cell as final study product. Cytotherapy 2018. [DOI: 10.1016/j.jcyt.2018.02.133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
|
50
|
Souza-Moreira L, Schlosser K, Tan Y, Salkhordeh M, Watpool I, Wang J, McIntyre L, Stewart D, Mei S. Effects of inflammatory cytokines on the immune-modulatory properties of Mesenchymal Stem Cell. Cytotherapy 2018. [DOI: 10.1016/j.jcyt.2018.02.138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
|