Formal Systematic Review Research Articles

A systematic review and meta-analysis of fall incidence and risk factors in elderly patients after total joint arthroplasty.

Background:Falls in the elderly have become a serious social problem worldwide. Approximately a third of persons fall at least once in the year after total joint arthroplasty (TJA), but preventing and treating falls is still challenging in clinical practice. Until now, no formal systematic review or meta-analysis was performed to summarize the risk factors of falls after TJA. The present study aimed to quantitatively and comprehensively conclude the risk factors of falls after TJA in elderly patients.Methods:The electronic databases to be searched include CNKI, Embase, Medline, and Cochrane central database (all up to November 2018). All studies on the risk factors of falls after TJA in elderly patients without language restriction were reviewed. Process of evaluation of identified studies and extraction of data were independently conducted by 2 reviewers, qualities of included studies were assessed using the Newcastle–Ottawa Scale. Data were pooled and a meta-analysis completed. All analyses were performed by the software Stata 11.0.Results:A total of 14 studies were included, which altogether included 1284456 patients with TJA, of them 12879 cases of falls occurred after surgery, suggesting the accumulated incidence of 13.1% and the prevalence of in-hospital falls was 1.0%. This study has provided evidence for the preventing of falls in the elderly patients who were underwent TJA. Outcome measures include advanced age, female, Overweight (BMI≥25 kg/m2), falls history, use of walking aid, diabetes, cardiac disease, hypertension, COPD and depressive symptoms. The ABC Scale was significantly negatively correlated with falls after lower extremity joint replacement.Conclusions:Related prophylaxis strategies should be implemented in elderly patients involved with above-mentioned risk factors to prevent falls after TJA.

Requirements of Mental Health Services During the COVID-19 Outbreak: A Systematic Review

Objectives: After the outbreak of a new viral disease in Wuhan, China, in late December 2019, COVID-19 in a very short time and rapidly became a global pandemic. Through a systematic review, the present paper investigated the requirements of Mental Health Services during the COVID-19 outbreak. Methods: A comprehensive search was conducted through PubMed and NLM Gateway (for MEDLINE), Institute of Scientific Information (ISI), and Scopus. PsychINFO and CINAHL data banks were also searched. The primary roots for the development of the search strategy developed based on the keywords of “Covid”, “mental health”, “care”, “services”. All relevant studies were included without any limitation of publication time or the papers’ language as it was not possible to conduct a formal systematic review given the nature of the publications. Instead, it was decided to conduct a mixed systematic and complementary narrative review covering different interested domains. Results: Out of 80 papers, after excluding duplications, 58 articles were selected for the refinement process. Three refining steps based on the titles, abstracts, and full texts led to data extraction from 4 eligible papers. Considering the importance of the problem, related findings, key points, and research findings were summarized and presented in terms of critical components of infrastructure and resources, including policy for at-risk groups, different approaches to mental health service delivery, indirect contexts for mental health service delivery, follow-up attitudes, and complementary research. The results of the study indicate that many studies considered the consequences of physical aspects and diagnostic symptoms. Thus, aspects of mental health have been either less focused or even neglected. In mental health consequences, immediate attention and intensive programs to assess mental health, preparation for support and treatment, and prevention services are emphasized. Conclusion: During the implementation of mental health interventions, to improve services and to consider the limitations and challenges of implementing programs, it is necessary to pay attention to the attitudes of target groups and their preference

Renewable energy performance evaluation studies using the data envelopment analysis (DEA): A systematic review

This article provides a systematic analysis of renewable energy performance using data envelopment analysis (DEA) to understand the diverging paths of renewable energy development for countries. In this review, 72 quantitative studies were identified using a multi-stage selection process. The review found that the DEA method can be used as an appropriate tool for performance evaluation of renewable energy studies' research. The DEA method can be applied critically for decision making, especially for policymakers in the renewable energy sector. The review also demonstrated that the DEA method, either traditional or advanced, can be comprehensively used to evaluate the performance of renewable energy studies depending on the objective of the research, as well as the complexity and accuracy of data issues. This review revealed that the selection of input and output factors used in DEA is sufficient enough to evaluate renewable energy performance. This review contributed to the current energy literature and filled in the gap with the addition of new knowledge on assessing renewable energy research studies intensively using a formal systematic literature review process. The review revealed that the development of DEA methodologies and applications in renewable energy should be expanded in the future. The results obtained from this review are both beneficial and inspirational for further research regarding the DEA application in renewable energy and provide valuable input for policymakers in decision-making processes.

The effects of shoe collar height on ankle sprain mechanics in athletes: A review of literature

Background: Our aim was to conduct a review to summarize the existing information regarding the effects of shoe collar height in altering ankle sprain mechanics in athletes. Methods: A systematic literature search of PubMed, Embase, MEDLINE, and SPORTDiscus was conducted in September 2019. Results: There were 10 studies published from 1993 to 2019 that were included. Most studies showed high-top shoes limited ankle sprain kinematics and increased resistance to inversion moment in static but not dynamic testing. High-top shoes were associated with delayed pre-landing ankle evertor muscle activation and smaller electromyography amplitudes. Conclusions: There is currently weak evidence to support that high-top shoes can limit ankle sprain kinematics in dynamic testing. Further studies with more consistent study interventions and outcome variables are needed to definitively establish the effects of shoe collar height on ankle sprain mechanics in athletes. The Translational Potential of this Article: Multiple studies on the effects of shoe collar height and ankle sprain mechanics have been performed but there is a lack of consistency in terms of study design, intervention, and outcome measures. A formal systematic review and meta-analysis were not applicable due to the heterogeneity of studies, and mixed results from these studies can be confusing to interpret, making further research on this topic difficult as a result of lack of future direction. We summarized the existing literature on this topic to provide a clearer picture and guide future research on this controversial matter.

Incidence and associated factors of delirium after orthopedic surgery in elderly patients: a systematic review and meta-analysis.

A total of 4.5-41.2% of orthopedic surgery patients experience delirium. Until now, no formal systematic review or meta-analysis was performed to summarize the risk factors of delirium after orthopedic surgery. The present study aimed to comprehensively and quantitatively conclude the risk factors of delirium after orthopedic surgery in elderly patients. A search was applied to Medline, Chinese National Knowledge Infrastructure (CNKI), Embase, and Cochrane central database (all up to February 2020). All studies on the risk factors of delirium after orthopedic surgery in elderly patients without language restriction were reviewed, and qualities of included studies were assessed using the Newcastle-Ottawa Scale. Data were pooled and a meta-analysis was completed. A total of 15 studies altogether included 10,053 patients with orthopedic surgery, 825 cases of delirium occurred after surgery, suggesting the accumulated incidence of 8.2%. Results of meta-analyses showed that age > 70years (odds ratio (OR) 3.78, 95% confidence interval (CI) 2.97-4.80), advanced age (standardized mean difference 0.82, 95% CI 0.54-1.09), male sex (OR 1.78, 95% CI 1.13-2.79), medical comorbidities (OR 2.18, 95% CI 1.23-3.88), malnutrition (OR 3.10, 95% CI 2.19-4.38), preoperative and postoperative haemoglobin (SMD - 0.37, 95% CI - 0.54 to - 0.19; SMD - 0.33, 95% CI - 0.55 to - 0.11), postoperative sodium (SMD - 0.52, 95% CI - 0.74 to - 0.29) and longer hospitalization after surgery (SMD 0.27, 95% CI 0.11-0.43), hearing impairment (OR 2.78, 95% CI 1.98-3.90), multiple medications (OR 1.36, 95% CI 1.21-1.52), psychotic drugs(OR 4.27, 95% CI 1.37-13.24), morphine (OR 1.97, 95% CI 1.11-3.51), cognitive impairment (OR 2.72, 95% CI 1.96-3.78), length of stay (SMD 0.26, 95% CI 0.14-0.39) and hip surgery (OR 1.63, 95% CI 1.08-2.48) were more likely to sustain delirium after hip surgery in elderly patients. ASA I and II was less likely to develop delirium after orthopedic surgery (OR 0.52, 95% CI 0.34-0.79). Related prophylaxis strategies should be implemented in the elderly involved with above-mentioned risk factors to prevent delirium after orthopedic surgery.

Effects of Hydraulic Ankle-Foot Prostheses on Gait in Individuals with Transtibial Limb Loss: A Scoping Review

ABSTRACT Introduction The purpose of this scoping review was to determine if sufficient evidence exists to conduct a formal systematic review or meta-analysis of hydraulic ankle-foot (HAF) prostheses and to determine if evidence statements could be synthesized relative to the effects of HAF prostheses on gait in individuals with transtibial limb loss. Methods Electronic database searches were conducted in MEDLINE, Embase, Web of Science, Scopus, and Proquest covering 1788 to 2017. Two reviewers independently completed screening and data extraction. Results The scoping review resulted in 15 articles that satisfied the inclusion/exclusion criteria. The majority of studies were completed in the United Kingdom and consisted of prospective protocols performed in research laboratories. All studies used the same HAF prosthesis intervention. The intervention studies reported a variety of biomechanical and patient-reported outcome measures. Conclusions Results of the scoping review indicate that there is a need to evaluate the quality of the HAF prosthetic literature with a systematic review or meta-analysis. Clinical Relevance There has been an increase in the number of commercially available passive hydraulic ankle-foot prostheses. This study provides an overview of evidence related to the effects of these HAF prostheses on transtibial prosthesis users' gait biomechanics and patient-reported outcomes. Walking speed was consistently reported as improved when using a hydraulic ankle-foot prosthesis as compared with a nonhydraulic ankle-foot prosthesis.

Graduate Employability and Competence Development in Higher Education—A Systematic Literature Review Using PRISMA

This paper aims to develop a systematic review on graduate employability and competence development, intending to present an international perspective on the matter. It analyses the role of higher education institutions in promoting the development of competences for employability. The Preferred Reporting Items for Systematic Reviews (PRISMA) statement was used as a formal systematic review guideline for data collection. Data was obtained from research studies over the period 2009–2019. The analysis included a total of 69 papers from Web of Science (WoS) and Scopus databases. Results show that Europe leads the number of publications on these topics during the past decade. One of the main issues associated with competence development and graduate employability found in the review is related to the (mis)match between university graduates’ competences and employers’ needs. Findings indicate that higher education institutions are concerned with using strategies to enhance the development of competences for graduate employability. Graduate employability and competence development around the world depend on a strong sense of innovation and collaboration practices implemented in higher education.

Identification and evaluation of epidemic prediction and forecasting reporting guidelines: A systematic review and a call for action

IntroductionHigh quality epidemic forecasting and prediction are critical to support response to local, regional and global infectious disease threats. Other fields of biomedical research use consensus reporting guidelines to ensure standardization and quality of research practice among researchers, and to provide a framework for end-users to interpret the validity of study results. The purpose of this study was to determine whether guidelines exist specifically for epidemic forecast and prediction publications. MethodsWe undertook a formal systematic review to identify and evaluate any published infectious disease epidemic forecasting and prediction reporting guidelines. This review leveraged a team of 18 investigators from US Government and academic sectors. ResultsA literature database search through May 26, 2019, identified 1467 publications (MEDLINE n = 584, EMBASE n = 883), and a grey-literature review identified a further 407 publications, yielding a total 1777 unique publications. A paired-reviewer system screened in 25 potentially eligible publications, of which two were ultimately deemed eligible. A qualitative review of these two published reporting guidelines indicated that neither were specific for epidemic forecasting and prediction, although they described reporting items which may be relevant to epidemic forecasting and prediction studies. ConclusionsThis systematic review confirms that no specific guidelines have been published to standardize the reporting of epidemic forecasting and prediction studies. These findings underscore the need to develop such reporting guidelines in order to improve the transparency, quality and implementation of epidemic forecasting and prediction research in operational public health.

Speech Intervention Effects for Childhood Apraxia of Speech: Quality Appraisal of Systematic Reviews

Purpose A number of justification have examined the effects of speech interventions on outcomes in childhood apraxia of speech (CAS). The findings have been summarized in the form of systematic reviews (SRs) and meta-analyses, which are used to support evidence-based clinical practice decisions. Yet without acceptable rigor, SRs/meta-analyses may be biased in their recommendations. We appraised the quality of existing SRs for CAS treatment using a tool developed within epidemiology, the AMSTAR-2 (A MeaSurement Tool to Assess Systematic Reviews). Method A search of five databases to identify published SRs that coalesced treatment research for CAS revealed six systematic reviews that met inclusion criteria. Two examiners coded each article with the AMSTAR-2 to rate the methodologic rigor of the SRs and extracted summary data. Results One rigorous systematic review included only one randomized controlled trial. A second moderately rigorous review examined multiple single participant research designs. The weight of high-quality evidence supported the positive effects of motor programming treatments for children with CAS. Conclusions Findings of six systematic reviews, two of which were conducted with relative rigor, suggest that motor programming treatments have the best evidence base for treatment decisions pertaining to CAS. Clinicians are referred to online resources to implement these treatments according to published protocols.

Reporting Outcomes and Outcome Measures in Cubital Tunnel Syndrome: A Systematic Review

Comparison between studies assessing outcomes after surgical treatment of cubital tunnel syndrome (CuTS) has proven to be difficult owing to variations in outcome reporting. This study aimed to identify outcomes and outcome measures used to evaluate postoperative results for CuTS. We performed computerized database searches of MEDLINE and EMBASE. Studies with 20 or more patients aged 18 and older who were undergoing medial epicondylectomy, endoscopic decompression, open simple decompression, or decompression with subcutaneous, submuscular, or intramuscular transposition for ulnar neuropathy at the elbow were included. Outcomes and outcome measures were extracted and tabulated. Of the 101 studies included, 45 unique outcomes and 31 postoperative outcome measures were identified. These included 7 condition-specific, clinician-reported instruments; 4 condition-specific, clinician-reported instruments; 8 patient-reported, generic instruments; 11 clinician-generated instruments; and one utility measure. Outcome measures were divided into 6 unique domains. Overall, 60% of studies used condition-specific outcome measures. The frequency of any condition-specific outcome measure ranged from 1% to 37% of included studies. There is marked heterogeneity in outcomes and outcome measures used to assess CuTS. A standardized core outcome set is needed to compare results of various techniques of cubital tunnel decompression. This study builds on the existing literature to support the notion that there is marked heterogeneity in outcomes and outcome measures used to assess CuTS. The authors believe that a future standardized set of core outcomes is needed to limit heterogeneity among studies assessing postoperative outcomes in CuTS to compare these interventions more easily and pool results in the form of systematic reviews and meta-analyses.

Variation in left ventricular cardiac magnetic resonance normal reference ranges: systematic review and meta-analysis.

AimsTo determine population-related and technical sources of variation in cardiac magnetic resonance (CMR) reference ranges for left ventricular (LV) quantification through a formal systematic review and meta-analysis.Methods and resultsThis study is registered with the International Prospective Register of Systematic Reviews (CRD42019147161). Relevant studies were identified through electronic searches and assessed by two independent reviewers based on predefined criteria. Fifteen studies comprising 2132 women and 1890 men aged 20–91 years are included in the analysis. Pooled LV reference ranges calculated using random effects meta-analysis with inverse variance weighting revealed significant differences by age, sex, and ethnicity. Men had larger LV volumes and higher LV mass than women [LV end-diastolic volume (mean difference = 6.1 mL/m2, P-value = 0.014), LV end-systolic volume (MD = 4 mL/m2, P-value = 0.033), LV mass (mean difference = 12 g/m2, P-value = 7.8 10−9)]. Younger individuals had larger LV end-diastolic volumes than older ages (20–40 years vs. ≥65 years: women MD = 14.0 mL/m2, men MD = 14.7 mL/m2). East Asians (Chinese, Korean, Singaporean-Chinese, n = 514) had lower LV mass than Caucasians (women: MD = 6.4 g/m2, P-value = 0.016; men: MD = 9.8 g/m2, P-value = 6.7 10−5). Between-study heterogeneity was high for all LV parameters despite stratification by population-related factors. Sensitivity analyses identified differences in contouring methodology, magnet strength, and post-processing software as potential sources of heterogeneity.ConclusionThere is significant variation between CMR normal reference ranges due to multiple population-related and technical factors. Whilst there is need for population-stratified reference ranges, limited sample sizes and technical heterogeneity precludes derivation of meaningful unified ranges from existing reports. Wider representation of different populations and standardization of image analysis is urgently needed to establish such reference distributions.

Identification and Recent Approaches for Evaluation and Management of Rehabilitation Concerns for Patients with Freeman–Burian Syndrome: Principles for Global Treatment

Freeman-Burian syndrome, formerly Freeman-Sheldon syndrome, is a rare congenital complex myopathic craniofacial syndrome that frequently involves extremity joint deformities, abnormal spinal curvatures, and chest wall mechanical problems that, together with spinal deformities, impair pulmonary function. As part of a clinical practice guideline development, we evaluated 19 rehabilitation-related articles from our formal systematic review, and from these and our experience, we describe rehabilitation considerations. Research in this area has widespread methodologic problems. While many challenges are present, much can be done to afford these patients a good quality of life through careful planning.

Algorithms in allergen immunotherapy in allergic rhinoconjunctivitis

Algorithms in allergen immunotherapy in allergic rhinoconjunctivitis

Making the Most of Systematic Reviews and Meta-analyses in Spine Surgery: A Primer for the Practicing Spine Surgeon.

Review. To provide practicing spine surgeons a primer with key insights for reading, interpreting, and clinically integrating systematic reviews and meta-analyses. Evidence-based medicine (EBM) refers to a family of standardized techniques for critical appraisal of clinical research. Within the contemporary spine literature, EBM is most commonly encountered in the form of systematic reviews and meta-analyses. Although these analytic techniques are potentially useful when appropriately applied to well-formulated questions with adequate primary data in the literature, the rapid and somewhat indiscriminate increase in volume of systematic reviews and meta-analyses published may be associated with an overall dilution in their quality, as well as misperceptions regarding the applicability of particular EBM studies to spine surgery in general. The collective experience of spine specialists with vested interests in advancing EBM and its utility was summarized into a primer. We emphasize components that are pertinent methodologically (search strategy, study number, meta-analysis, bias, and certainty), and pertinent clinically (outcomes) to interpreting, and clinically integrating systematic reviews and meta-analyses into spine surgery practice. Armed with these insights into these five perspectives, we anticipate that practicing spine surgeons will be better equipped to interpret systematic reviews and meta-analyses in a fashion that will meaningfully impact their patient care. 2.

Paget-Schroetter syndrome: A contemporary review of the controversies in management.

To assess the current evidence, controversies and technologies behind the various approaches and steps in the management of Paget-Schroetter syndrome. We performed a narrative review based on a literature search in Embase, Medline, Pubmed and Google Scholar through keyword searching related to upper extremity deep vein thrombosis, Paget-Schroetter syndrome and venous thoracic outlet syndrome. There is a paucity of high-quality evidence assessing the efficacy of contemporary approaches for the management of acute upper extremity deep vein thrombosis which, though promising, is largely limited to single institution case studies and small series. As a result, a formal systematic review could not be performed. Paget-Schroetter syndrome is a rare condition, whose management approaches are largely guided by the accumulated expertise and clinical experience of vascular specialists. In the absence of randomized controlled trials, current practice has been guided by retrospective reviews and experience. Modern approaches and protocols appear to remain distinct between health care facilities, but have common features including early clot lysis, surgical decompression with first rib resection, followed by adjunctive open or endovascular procedures. Further high-quality level 1 evidence and research are required in order to standardize treatment for this condition.

Risk of Death and Amputation with Use of Paclitaxel-Coated Balloons in the Infrapopliteal Arteries for Treatment of Critical Limb Ischemia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

A formal systematic review and study-level meta-analysis of randomized controlled trials investigating treatment of the infrapopliteal arteries with paclitaxel-coated balloons compared with conventional balloon angioplasty for critical limb ischemia (CLI) was conducted. Medical databases and online content were last screened in September 2019. The primary safety and efficacy endpoint was amputation-free survival defined as freedom from all-cause death and major amputation. Target lesion revascularization (TLR) constituted a secondary efficacy endpoint. Summary effects were synthesized with a random-effects model. Some 8 randomized controlled trials with 1,420 patients (97% CLI) were analyzed up to 1 year follow-up. Amputation-free survival was significantly worse in case of paclitaxel (13.7% crude risk of death or limb loss compared to 9.4% in case of uncoated balloon angioplasty; hazard ratio 1.52; 95% confidence interval: 1.12-2.07, p = .008). TLR was significantly reduced in case of paclitaxel (11.8% crude risk of TLR versus 25.6% in control; risk ratio 0.53; 95% confidence interval: 0.35-0.81, p = .004). The harm signal was evident when examining the high-dose (3.0-3.5μg/mm2) devices, but attenuated below significance in case of a low-dose (2.0 μg/mm2) device. Actual causes remain largely unknown, but non-target paclitaxel embolization is a plausible mechanism.

Systematic review protocol examining the influence of surgeon personality on perioperative decision making in abdominal surgery

IntroductionThere is limited published literature exploring how the personality traits of surgeons may influence preoperative decision making, particularly in the context of visceral/abdominal surgery. Multiple validated personality scoring systems exist...

Recommendations for the Study of Vulvar Pain in Women, Part 2: Methodological Challenges

IntroductionChronic vulvar pain is a multidimensional condition with great variability in clinical presentation among affected women. In a companion article, part 1, we reviewed and recommended assessment and measurement tools for vulvar pain and related outcomes with a view toward improving consistency and comparison across studies. Yet methodological challenges to conducting research with this population remain and can further hinder conclusions regarding etiology and treatment. AimTo discuss methodological challenges to conducting vulvar pain research alongside recommended solutions. MethodsThe expert authors reviewed the scientific evidence related to the study of vulvar pain and made decisions regarding methodological challenges and mitigation strategies via discussion and consensus. Main Outcome MeasureWe articulated key challenges to conducting research in this area and formulated recommendations for mitigating these challenges. ResultsChallenges to the field include selection and sample biases, heterogeneity of the condition, inclusion of the partner, and neglect of the multidimensional aspects of vulvar pain. 2 key recommendations are more careful and detailed tracking and characterization of research samples and greater multidisciplinary collaboration to better capture the complexity of chronic vulvar pain. Clinical ImplicationsThis methodological critique points to several challenges to clinical research with populations struggling with chronic vulvar pain and makes suggestions for how to mitigate these issues. Strength & LimitationsComments in this expert review raise awareness regarding core challenges to the study of vulvar pain and can inform study design of clinical research with this population. The content of this review is based on expert knowledge and opinion rather than a formal systematic review or extended consultation process. ConclusionA careful reflection upon methodological challenges facing clinical research of vulvar pain and ways to mitigate such challenges is crucial for improving the quality, generalizability, and uptake of research findings.Rosen NO, Bergeron S, Pukall CF. Recommendations for the Study of Vulvar Pain in Women, Part 2: Methodological Challenges. J Sex Med 2020; 17:595–602.

Management of Outpatient Hemodialysis During the COVID-19 Pandemic: Recommendations From the Canadian Society of Nephrology COVID-19 Rapid Response Team.

Purpose:To collate best practice recommendations on the management of patients receiving in-center hemodialysis during the COVID-19 pandemic, based on published reports and current public health advice, while considering ethical principles and the unique circumstances of Canadian hemodialysis units across the country.Sources of information:The workgroup members used Internet search engines to retrieve documents from provincial and local hemodialysis programs; provincial public health agencies; the Centers for Disease Control and Prevention; webinars and slides from other kidney agencies; and nonreviewed preprints. PubMed was used to search for peer-reviewed published articles. Informal input was sought from knowledge users during a webinar.Methods:Challenges in the care of hemodialysis patients during the COVID-19 pandemic were highlighted within the Canadian Senior Renal Leaders Forum discussion group. The Canadian Society of Nephrology (CSN) developed the COVID-19 rapid response team (RRT) to address these challenges. They identified a pan-Canadian team of clinicians and administrators with expertise in hemodialysis to form the workgroup. One lead was chosen who drafted the initial document. Members of the workgroup reviewed and discussed all recommendations in detail during 2 virtual meetings on April 7 and April 9. Disagreements were resolved by consensus. The document was reviewed by the CSN COVID-19 RRT, an ethicist, an infection control expert, a community nephrologist, and a patient partner. Content was presented during an interactive webinar on April 11, 2020 attended by 269 kidney health professionals, and the webinar and first draft of the document were posted online. Final revisions were made based on feedback received until April 13, 2020. CJKHD editors reviewed the parallel process peer review and edited the manuscript for clarity.Key findings:Recommendations were made under the following themes: (1) Identification of patients with COVID-19 in the dialysis unit, (2) hemodialysis of patients with confirmed COVID-19, (3) hemodialysis of patients not yet known to have COVID-19, (4) visitors; (5) testing for COVID-19 in the dialysis unit; (6) resuscitation, (6) routine hemodialysis care, (7) hemodialysis care under fixed dialysis resources.Limitations:Because of limitations of time and resources, and the large number of questions, formal systematic review was not undertaken. The recommendations are based on expert opinion and subject to bias. The parallel review process that was created may not be as robust as the standard peer review process.Implications:We hope that these recommendations provide guidance for dialysis unit directors, clinicians, and administrators on how to limit risk from infection and adverse outcomes, while providing necessary dialysis care in a setting of finite resources. We also identify a number of resource allocation priorities, which we hope will inform decisions at provincial funding agencies.

Cardiovascular Risk Assessment Using Ultrasonographic Surrogate Markers of Atherosclerosis and Arterial Stiffness in Patients With Chronic Renal Impairment: A Narrative Review of the Evidence and a Critical View of Their Utility in Clinical Practice.

Purpose of the review:Validated tools to improve cardiovascular disease (CVD) risk assessment and mortality in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) are lacking. Noninvasive measures of arteriosclerosis and subclinical atherosclerosis such as pulse wave velocity (PWV) and carotid intima-media thickness (cIMT), respectively, have emerged as promising risk stratification tools and potential modifiable biomarkers. Their wide use as surrogate markers in clinical research studies is based on the strong pathophysiological links with CVD. However, whether their effect as risk stratification or intervention targets is superior to established clinical approaches is uncertain. In this review, we examine the evidence on the utility of PWV, cIMT, and plaque assessment in routine practice and highlight unanswered questions from the clinician’s perspective.Sources of information:Electronic databases PubMed and Google Scholar were searched until February 2020.Methods:This narrative review is based on peer-reviewed meta-analyses, national and international societies’ guidelines, and on focused critical review of recent original studies and landmark studies in the field.Key findings:Although patients with CKD are considered in the high-risk CVD groups, there is still need for tools to improve risk stratification and individualized management strategies within this group of patients. Carotid intima-media thickness is associated with all-cause mortality, CVD mortality, and events in CKD and hemodialysis cohorts. However, the evidence that measurement of cIMT has a clinically meaningful role over and above existing risk scores and management strategies is limited. Plaque assessment is a better predictor than cIMT in non-CKD populations and it has been incorporated in recent nonrenal-specific guidelines. In the CKD population, one large observational study provided evidence for a potential role of plaque assessment in CKD similar to the non-CKD studies; however, whether it improves prediction and outcomes in CKD is largely understudied. Pulse wave velocity as a marker of arterial stiffness has a strong pathophysiological link with CVD in CKD and numerous observational studies demonstrated associations with increased cardiovascular risk. However, PWV did not improve CVD reclassification of dialysis patients when added to common risk factors in a reanalysis of ESRD cohorts with available PWV data. Therapeutic strategies to regress PWV, independently from blood pressure reduction, have not been studied in well-conducted randomized trials.Limitations:This study provides a comprehensive review based on extensive literature search and critical appraisal of included studies. Nevertheless, formal systematic literature review and quality assessment were not performed and the possibility of selection bias cannot be excluded.Implications:Larger, prospective, randomized studies with homogeneous approach, designed to answer specific clinical questions and taking into consideration special characteristics of CKD and dialysis, are needed to study the potentially beneficial role of cIMT/plaque assessment and PWV in routine practice.