Ovid SP Research Articles

Injectable local anaesthetic agents for dental anaesthesia.

Injectable local anaesthetic agents for dental anaesthesia.

Association of dyslipidemia and lipid-lowering treatment with risk of postoperative cognitive dysfunction (POCD): A systematic review and meta-analysis

Introduction Postoperative cognitive dysfunction (POCD) is a common complication after surgery and involves a spectrum of symptoms spanning from mild to severe cognitive deficits that affect the daily lives of patients. Despite occurring in up to one third of older patients during the first few months after surgery, POCD is poorly characterized in terms of its epidemiology. Lipid imbalance in older age has frequently been linked to age-related cognitive impairment, but its role in determining patients’ risk of POCD is presently unknown. We therefore conducted a systematic review and meta-analysis of published research on the associations of dyslipidemia before surgery, use of lipid-lowering treatment before surgery and risk of POCD. Methods PubMed, Ovid SP and the Cochrane Database were searched for longitudinal studies that reported on associations of any measure of dyslipidemia (high total cholesterol, high low-density lipoprotein cholesterol, high triglycerides, low high-density lipoprotein; hypercholesterolemia) or on lipid-lowering treatment with POCD as relative risks (RR) or odds ratios. Any definition of POCD was permitted. Fixed-effects inverse variance models combined effects. Observational and intervention studies were considered separately. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) and Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed and the search was registered on the PROSPERO database (CRD42017069013). Results Of 205 articles, 17 studies totaling 2725 patients (mean age 67 years) were included. All had observational design. Median follow-up period was 7 days (range 1 day to 4 years) and surgical procedures were most commonly of the heart or carotid artery. Studies focused almost exclusively on hypercholesterolemia (either not further defined, or defined through self-report or laboratory analysis) as a measure of dyslipidemia (n = 12 studies) and on statins as lipid-lowering treatment (n = 8 studies). Few other parameters of dyslipidemia were investigated. Of all included studies, only 2 had set out to address the present research question. All of the remaining investigations reported on pre-surgery exposure to dyslipidemia or lipid-lowering treatment and POCD risk in descriptive tables showing characteristics of patients with POCD compared with cognitively stable patients. Statistical adjustment for potential confounders was rare. In meta-analysis, we found no association of hypercholesterolemia with POCD risk (RR: 0.93; 95% CI: 0.80, 1.08; P = 0.34), whereas statin use before surgery was associated with a reduced POCD risk (RR: 0.81; 95% CI: 0.67, 0.98; P = 0.03). Information on duration of statin treatment was lacked throughout. Additional evidence from 2 trial studies that failed to meet inclusion criteria was conflicting. One reported better post-surgery cognitive function patients receiving rosuvastatin for 7 to 10 days before cardiac surgery compared with patients not receiving that treatment at 10 to 14-day follow-up but lacked a placebo–controlled group; the other of critically ill patients found no effect of statin treatment initiated immediately after surgery versus placebo on POCD risk at 6-month follow-up. Conclusion In this meta-analysis we found no association of hypercholesterolemia with risk of POCD, but we found that use of statins was associated with a reduced risk. Future epidemiological studies should consider collecting data on patients’ treatment history, including indication, drug type, dosage and treatment duration, and should strategically adjust for potential confounders in view to disentangle parameters of dyslipidemia and lipid-lowering treatment in POCD risk prediction. If those types of studies were to support the preliminary evidence presented here, trial studies could determine the causality in the reduced risk of POCD seen in statin users, as trials are inadequate at present in terms of study number and design.

Peripheral Nerve Blocks for Hip Fractures: A Cochrane Review.

This review focuses on the use of peripheral nerve blocks as preoperative analgesia, as postoperative analgesia, or as a supplement to general anesthesia for hip fracture surgery and tries to determine if they offer any benefit in terms of pain on movement at 30 minutes after block placement, acute confusional state, myocardial infarction/ischemia, pneumonia, mortality, time to first mobilization, and cost of analgesic. Trials were identified by computerized searches of Cochrane Central Register of Controlled Trials (2016, Issue 8), MEDLINE (Ovid SP, 1966 to 2016 August week 1), Embase (Ovid SP, 1988 to 2016 August week 1), and the Cumulative Index to Nursing and Allied Health Literature (EBSCO, 1982 to 2016 August week 1), trials registers, and reference lists of relevant articles. Randomized controlled trials involving the use of nerve blocks as part of the care for hip fractures in adults aged 16 years and older were included. The quality of the studies was rated according to the Cochrane tool. Two authors independently extracted the data. The quality of evidence was judged according to the Grading of Recommendations, Assessment, Development, and Evaluations Working Group scale. Based on 8 trials with 373 participants, peripheral nerve blocks reduced pain on movement within 30 minutes of block placement: standardized mean difference, -1.41 (95% confidence interval [CI], -2.14 to -0.67; equivalent to -3.4 on a scale from 0 to 10; I statistic = 90%; high quality of evidence). The effect size was proportional to the concentration of local anesthetic used (P < .00001). Based on 7 trials with 676 participants, no difference was found in the risk of acute confusional state: risk ratio, 0.69 (95% CI, 0.38-1.27; I statistic = 48%; very low quality of evidence). Based on 3 trials with 131 participants, the risk for pneumonia was decreased: risk ratio, 0.41 (95% CI, 0.19-0.89; I statistic = 3%; number needed-to-treat for additional beneficial outcome, 7 [95% CI, 5-72]; moderate quality of evidence). No difference was found for the risk of myocardial ischemia or death within 6 months but the number of participants included was well below the optimum information size for these 2 outcomes. Based on 2 trials with 155 participants, peripheral nerve blocks also reduced the time to first mobilization after surgery: mean difference, -11.25 hours (95% CI, -14.34 to -8.15 hours; I statistic = 52%; moderate quality of evidence). From 1 trial with 75 participants, the cost of analgesic drugs when used as a single-shot block was lower: standardized mean difference, -3.48 (95% CI, -4.23 to -2.74; moderate quality of evidence). There is high-quality evidence that regional blockade reduces pain on movement within 30 minutes after block placement. There is moderate quality of evidence for a decreased risk of pneumonia, reduced time to first mobilization, and reduced cost of analgesic regimen (single-shot blocks).

Abstract 247: Is Oxygen Therapy Beneficial in Acute Myocardial Infarction? A Meta-Analysis

Background: Supplemental oxygen (O2) is beneficial in patients with acute myocardial infarction (AMI) who have hypoxemia. However in patients who have suspected AMI without hypoxemia, the benefit of O2 remains uncertain. We conducted a meta-analysis, including the recent landmark trials, to establish the efficacy and safety of O2 in AMI. Methods: We searched Medline, Embase, and Ovid SP databases for randomized clinical trials that compared O2 with room air in suspected AMI without hypoxemia. Hypoxemia was defined as O2 saturation of &lt;90%. The primary endpoint was all-cause mortality. Data were pooled by the random effects model and I2 was used to assess for the heterogeneity. Results: A total of 6 studies including 8193 participants were included in the final analysis. On pooled analysis, there was no significant difference between the two arms in 30-day all-cause mortality (OR=1.10 [0.67, 1.80]; p=0.70), cardiogenic shock (OR=0.75 [0.49, 1.16]; p=0.19), recurrent myocardial infarction (OR=1.24 [0.46, 3.34]; p=0.67) and left ventricular ejection fraction (SMD= -1.95 [-4.76, 0.85]; p=0.17). Conclusion: Contrary to the routine clinical practice, our analysis shows that O2 administration does not provide any benefit in AMI patients who have normal oxygen saturation. It is reasonable to reserve O2 only for patients with AMI and hypoxemia.

Does dexmedetomidine have an antiarrhythmic effect on cardiac patients? A meta-analysis of randomized controlled trials.

BackgroundCardiac surgery patients often experience several types of tachyarrhythmias after admission to the intensive care unit (ICU), which increases mortality and morbidity. Dexmedetomidine (DEX) is a popular medicine used for sedation in the ICU, and its other pharmacological characteristics are gradually being uncovered.PurposeTo determine whether DEX has an antiarrhythmic effect after cardiac surgery.MethodsThe three primary databases MEDLINE, Embase (OVID SP) and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched, and all English-language and randomized control-designed clinical publications comparing DEX to control medicines for sedation after elective cardiac surgery were included. Two colleagues independently extracted the data and performed other quality assessments. A subgroup analysis was performed according to the different medicines used and whether cardiopulmonary bypass (CPB) was applied. All tachyarrhythmias that occurred in the atria and ventricles were analyzed.ResultsA total of 1295 patients in 9 studies met the selection criteria among 2587 studies that were screened. After quantitative synthesis, our results revealed that the DEX group was associated with a lower incidence of ventricular arrhythmia (VA, OR 0.24, 95% CI 0.09–0.64, I2 = 0%, P = 0.005) than the control group. Subgroup analysis did not reveal a significant difference between the DEX and propofol subgroups (OR 0.13, 95% CI 0.03–0.56, I2 = 0%, P = 0.007). Additionally, no difference in the incidence of atrial fibrillation (AF) was observed regardless of the different control medicines (OR 0.82, 95% CI 0.60–1.10, I2 = 25%, P = 0.19) or whether CPB was applied.ConclusionsThis meta-analysis revealed that DEX has an antiarrhythmic effect that decreases the incidence of VA compared to other drugs used for sedation following cardiac surgery. DEX may not have an effect on AF, but cautious interpretation should be exercised due to high heterogeneity.

Can dexmedetomidine reduce atrial fibrillation after cardiac surgery? A systematic review and meta-analysis.

PurposeCardiac surgery patients always present with atrial fibrillation (AF) after admission to the intensive care unit, leading to high mortality and lengthy hospitalization. Dexmedetomidine (DEX) is a popular medication used for sedation in the intensive care unit; however, whether it can reduce AF needs to be analyzed.Materials and methodsThree primary databases, Medline, Embase (Ovid SP) and the Cochrane Central Register of Controlled Trials (CENTRAL), were searched. All English language and randomized control designed clinical publications comparing DEX to control medicines for sedation after elective cardiac surgery were included. Two independent colleagues conducted the data extraction and quality assessments. The subgroup analysis was performed according to the medicine used, age, AF history, and whether previous beta-blocker premedication and cardiopulmonary bypass (CPB) were applied. The overall incidence of AF was analyzed.ResultsA total of 1,295 patients in nine studies met the selection criteria among 2,587 studies screened from the database. After quantitative synthesis, our results revealed that the DEX group was not associated with a decreased incidence of AF compared with the placebo (risk ratio [RR] 0.76, 95% CI 0.37, 1.55, P=0.44) and morphine groups (RR 0.86, 95% CI 0.56, 1.31, P=0.48). Subgroup analysis also indicated that the DEX vs propofol comparison exhibited no difference: 1) for patients of age >60 years (P=0.69) or ≤60 years (P=0.69); 2) under CPB surgery (P=0.45) or without CPB surgery (P=0.88); 3) with beta-blocker premedication (P=0.32) or without beta-blocker premedication (P=0.90); and 4) with AF history (RR 1.07, 95% CI 0.85, 1.36, P=0.57) or without AF history (P=0.30).ConclusionThis meta-analysis revealed that DEX could not reduce the incidence of AF compared to control medicines following cardiac surgery. DEX may have an increased influence on AF occurrence if patients had a history of AF. However, cautious interpretation should be made due to high clinical heterogeneity.

Critical appraisal of nonrandomized studies-A review of recommended and commonly used tools.

When randomized controlled trial data are limited or unavailable, or to supplement randomized controlled trial evidence, health technology assessment (HTA) agencies may rely on systematic reviews of nonrandomized studies (NRSs) for evidence of the effectiveness of health care interventions. NRS designs may introduce considerable bias into systematic reviews, and several methodologies by which to evaluate this risk of bias are available. This study aimed to identify tools commonly used to assess bias in NRS and determine those recommended by HTA bodies. Appraisal tools used in NRS were identified through a targeted search of systematic reviews (January 2013-March 2017; MEDLINE and EMBASE [OVID SP]). Recommendations for the critical appraisal of NRS by expert review groups and HTA bodies were reviewed. From the 686 studies included in the narrative synthesis, 48 critical appraisal tools were identified. Commonly used tools included the Newcastle-Ottawa Scale, the methodological index for NRS, and bespoke appraisal tools. Neither the Cochrane Handbook nor the Centre for Reviews and Dissemination recommends a particular instrument for the assessment of risk of bias in NRS, although Cochrane has recently developed their own NRS critical appraisal tool. Among HTA bodies, only the Canadian Agency for Drugs and Technologies in Health recommends use of a specific critical appraisal tool-SIGN 50 (for cohort or case-control studies). Several criteria including reporting, external validity, confounding, and power were examined. There is no consensus between HTA groups on the preferred appraisal tool. Reviewers should select from a suite of tools on the basis of the design of studies included in their review.

Personally tailored activities for improving psychosocial outcomes for people with dementia in long-term care.

Background People with dementia who are being cared for in long‐term care settings are often not engaged in meaningful activities. Offering them activities which are tailored to their individual interests and preferences might improve their quality of life and reduce challenging behaviour.

Magnetic resonance perfusion for differentiating low-grade from high-grade gliomas at first presentation.

Magnetic resonance perfusion for differentiating low-grade from high-grade gliomas at first presentation.

Clinicopathological, genomic and immunological factors in colorectal cancer prognosis.

Numerous factors affect the prognosis of colorectal cancer (CRC), many of which have long been identified, such as patient demographics and the multidisciplinary team. In more recent years, molecular and immunological biomarkers have been shown to have a significant influence on patient outcomes. Whilst some of these biomarkers still require ongoing validation, if proven to be worthwhile they may change our understanding and future management of CRC. The aim of this review was to identify the key prognosticators of CRC, including new molecular and immunological biomarkers, and outline how these might fit into the whole wider context for patients. Relevant references were identified through keyword searches of PubMed and Embase Ovid SP databases. In recent years there have been numerous studies outlining molecular markers of prognosis in CRC. In particular, the Immunoscore® has been shown to hold strong prognostic value. Other molecular biomarkers are useful in guiding treatment decisions, such as mutation testing of genes in the epidermal growth factor receptor pathway. However, epidemiological studies continue to show that patient demographics are fundamental in predicting outcomes. Current strategies for managing CRC are strongly dependent on clinicopathological staging, although molecular testing is increasingly being implemented into routine clinical practice. As immunological biomarkers are further validated, their testing may also become routine. To obtain clinically useful information from new biomarkers, it is important to implement them into a model that includes all underlying fundamental factors, as this will enable the best possible outcomes and deliver true precision medicine.

What are the predictors, barriers and facilitators to effective management of acute pain in children by ambulance services? A mixed-methods systematic review protocol.

Introduction:The management of pain is complex, especially in children, as age, developmental level, cognitive and communication skills and associated beliefs must be considered. Without effective pain treatment, children may suffer long-term changes in stress hormone responses and pain perception and are at risk of developing posttraumatic stress disorder. Pre-hospital analgesic treatment of injured children is suboptimal, with very few children in pain receiving analgesia. The aim of this review is to identify predictors, barriers and facilitators to effective management of acute pain in children by ambulance services.Methods:A mixed-methods approach has been adopted due to the research question lending itself to qualitative and quantitative inquiry. The segregated methodology will be used where quantitative and qualitative papers are synthesised separately, followed by mixed-methods synthesis (meta-integration). We will search from inception: MEDLINE, CINAHL and PsycINFO via EBSCOHost, EMBASE via Ovid SP, Web of Science and Scopus. The Cochrane Library, the Joanna Briggs Institute, PROSPERO, ISRCTN and ClinicalTrials.gov will be searched. We will include empirical qualitative and quantitative studies. We will exclude animal studies, reviews, audits, service evaluations, simulated studies, letters, Best Evidence Topics, case studies, self-efficacy studies, comments and abstracts. Two authors will perform full screening and selection, data extraction and quality assessment. GRADE and CERQual will determine the confidence in cumulative evidence.Discussion:If confidence in the cumulative evidence is deemed Moderate, Low or Very Low, then this review will inform the development of a novel mixed-methods sequential explanatory study which aims to comprehensively identify predictors, barriers and facilitators to effective pain management of acute pain in children within ambulance services. Future research will be discussed among authors if confidence is deemed High.Systematic Review Registration: PROSPERO: CRD42017058960.

Comparison of surgical and conservative treatment of Rockwood type-III acromioclavicular dislocation: A meta-analysis.

There is no consensus on the effects of surgical versus conservative treatment on Rockwood type-III dislocation of the acromioclavicular joint in general orthopedic practice. The objective of this meta-analysis was to compare the clinical outcomes of patients managed surgically and conservatively following type-III acromioclavicular (AC) dislocation. The Cochrane Library, EMBASE, MEDLINE via Ovid SP, and PubMed databases were searched for randomized controlled trials and observational studies. Patient data were pooled using standard meta-analytic approaches. For continuous variables, the weighted mean difference was used. For dichotomous data, the odds ratio was calculated. The current analysis included 10 trials on this topic, and the results demonstrated that there were no significant differences between surgical and conservative treatment in terms of pain, weakness, tenderness, post-traumatic arthritis, restriction of strength, unsatisfactory function, and scores (Constant, UCLA, Imatani, SST, DASH, Larsen). Analyses of ossification of the coracoclavicular ligament (OR = 1.62, 95% CI = 1.01-2.61) and osteolysis of the lateral clavicle (OR = 2.87, 95% CI = 1.27-6.52) suggested better function with conservative treatment versus surgical treatment, but the latter was superior to conservative treatment with regard to loss of anatomic reduction. Only 1 study showed a higher acromioclavicular joint instability score for surgical management compared with conservative management (P < .00001). In the management of Rockwood type-III AC dislocation, conservative treatment is superior to surgical treatment. Nonoperative treatment results in a lower incidence of ossification of the coracoclavicular ligament and osteolysis of the lateral clavicle compared with operative treatment. However, there was no statistical difference between operative and nonoperative treatment in terms of clinical outcomes.

Protocol for the systematic review of the reporting of transoral robotic surgery

IntroductionTransoral robotic surgery (TORS) has been adopted in some parts of the world as an innovative approach to the resection of oropharyngeal tumours. The development, details and outcomes of early-to-later...

The effect of no drainage in patients who underwent thyroidectomy with neck dissection: A systematic review and meta-analysis.

To evaluate the effect of no drainage in patients who underwent thyroidectomy and neck lymph node dissection. We followed the methodological standard expected by Cochrane. We searched the following databases by March 23, 2017: PubMed, The Cochrane Library, EMBASE via Ovid SP, and Medline via Ovid SP. Two reviewers screened the studies and extracted the data. Randomized controlled trials (RCTs) or nonrandomized interventional studies assessing the effect of no drainage following thyroidectomy with lymph node dissection were included. Three studies with 387 participants were included. There was no statistical difference between groups for the overall perioperative complications (2 RCTs, n = 234, RR 1.56, 95% CI 0.53-4.64), or specific complications such as seroma (2 RCTs, n = 234, RR 1.81, 95% CI 0.46-7.07), hematoma (2 RCTs, n = 234, RR 0.72, 95% CI 0.11-4.83) or hemorrhage (1 RCT, n = 69, RR 0.29, 95% CI 0.01-6.87). One case required reoperation due to hemorrhage in the drainage group was reported in 1 study (n = 32). No mortality was reported. Two studies (n = 234) stated a longer hospital stay in the drainage group than that in the group without drainage. There was moderate or serious bias for the risk of bias of included studies. The effect of no-drainage in patients with thyroid cancer who received thyroidectomy with neck dissections remains uncertain, since there are very few studies that addressed the question. Drainage may lead to longer hospital stay than nondrainage. More randomized or nonrandmized studies are required to address this issue.

Systematic evaluation of different doses of cyclophosphamide induction therapy for lupus nephritis.

Objective:This study systemically evaluated the efficacy and safety of intermittent intravenous pulse therapy with different doses of cyclophosphamide (CTX) for the treatment of lupus nephritis (LN).Methods:We screened the Chinese Journal Full-text Database (CNKI, 1994–present), China Biology Medicine (CBMdisc, 1978–present), VIP Database for Chinese Technical Periodicals (1989–present), PubMed (1948–present), MEDLINE (Ovid SP, 1946–present), Embase (1947–present), and the Cochrane controlled trials register (13, 2017). Literature reports were selected according to the inclusion and exclusion criteria, effective data were extracted, research quality was evaluated, and RevMan5.2 was used for meta-analysis.Results:Seven randomized controlled studies were included, consisting of 655 patients. The meta-analysis results showed no significant differences between the low- and high-dose cyclophosphamide groups in partial, complete, and total remission rates as well Systemic Lupus Erythematosus Disease Activity Index (SLEDAI). Furthermore, there were no significant differences between the 2 groups in hematologic toxicity and gastrointestinal reaction, but the risk of infection (risk ratio [RR] = 0.74, 95% confidence interval [CI], 0.56–0.98, total effect inspection Z = 2.12, P = .03), and menstrual disorder (RR = 0.46, 95% CI, 0.31–0.69, total effect inspection Z = 3.83, P = .0001) decreased in the low-dose cyclophosphamide group.Conclusions:There was no obvious difference between the low- and high-dose cyclophosphamide groups in efficacy in the treatment of lupus nephritis, but the risk of infection and menstrual disorder significantly decreased in the low-dose group.

The clinical surrogate definition of the trigeminocardiac reflex: Development of an optimized model according to a PRISMA-compliant systematic review.

Background:The trigeminocardiac reflex (TCR) is defined as sudden onset of parasympathetic dysrhythmias including hemodynamic irregularities, apnea, and gastric hypermotility during stimulation of sensory branches of the trigeminal nerve. Since the first description of the TCR 1999, there is an ongoing discussion about a more flexible than the existing clinical definition. Aim of this work was to create a clinical surrogate definition through a systematic review of the literature.Methods:In this meta-analysis study, literature about TCR occurrences was, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement, systematically identified through various search engines including PubMed (Medline), Embase (Ovid SP), and ISI Web of Sciences databases from January 2005 to August 2015. TCR was defined as a drop of heart rate (HR) below 60 bpm or 20% to the baseline. We extracted detailed data about hemodynamic changes and searched for connections between arterial blood pressure (BP) and HR changes during such episodes.Results:Overall 45 studies harboring 57 patients were included in the study but only 32 patients showed sufficient data for final analyze. HR showed a nonlinear behavior with a “tipping point” phenomena that differs in variance from the central/peripheral (20–30% drop) to ganglion (40–49% drop). BP showed a linear behavior with a “central limit” phenomena not differing in variance in the whole subgroup (30–39% drop). An analyzation of the correlation between BP and HR showed a trend to a linear correlation.Conclusions:We can show for the first time that HR is the dominant variable in the TCR and present a new surrogate definition model. This model and the role of BP must be better investigated in further studies.

The use of preoperative aspirin in cardiac surgery: A systematic review and meta-analysis.

Despite the fact that aspirin is of benefit to patients following coronary artery bypass grafting (CABG), continuation or administration of preoperative aspirin before CABG or any cardiac surgical procedure remains controversial. Therefore, we performed a systematic review and meta-analysis to assess the influence of preoperative aspirin administration on patients undergoing cardiac surgery. Medline database was searched using OVID SP interface. Similar searches were performed separately in EMBASE, PubMed, and Cochrane Central Registry of Controlled Trials. Twelve randomized controlled trials and 28 observational studies met our inclusion criteria and were included in the meta-analysis. The use of preoperative aspirin in patients undergoing CABG at any dose is associated with reduced early mortality as well as a reduced incidence of postoperative acute kidney injury (AKI). Low-dose aspirin (≤160 mg/d) is associated with a decreased incidence of perioperative myocardial infarction (MI). Administration of preoperative aspirin at any dose in patients undergoing cardiac surgery increases postoperative bleeding. Despite this effect of preoperative aspirin, it did not increase the rates of surgical re-exploration due to excessive postoperative bleeding nor did it increase the rates of packed red blood cell transfusions (PRBC) when preoperative low-dose aspirin (≤160 mg/d) was administered. Preoperative aspirin increases the risk for postoperative bleeding. However, this did not result in an increased need for chest re-exploration and did not increase the rates of PRBC transfusion when preoperative low-dose (≤160 mg/d) aspirin was administered. Aspirin at any dose is associated with decreased mortality and AKI and low-dose aspirin (≤160 mg/d) decreases the incidence of perioperative MI.

Chloral hydrate as a sedating agent for neurodiagnostic procedures in children.

Chloral hydrate as a sedating agent for neurodiagnostic procedures in children.

Nerve blocks or no nerve blocks for pain control after elective hip replacement (arthroplasty) surgery in adults.

It is estimated that over 300,000 total hip replacements are performed each year in the USA. For European countries, the number of hip replacement procedures per 100,000 people performed in 2007 varied from less than 50 to over 250. To facilitate postoperative rehabilitation, pain must be adequately treated. Peripheral nerve blocks and neuraxial blocks have been proposed to replace or supplement systemic analgesia. We aimed to compare the relative effects (benefits and harms) of the different nerve blocks that may be used to relieve pain after elective hip replacement in adults. We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 12, 2016), MEDLINE (Ovid SP) (1946 to December Week 49, 2016), Embase (Ovid SP) (1980 to December week 49, 2016), CINAHL (EBSCO host) (1982 to 6 December 2016), ISI Web of Science (1973 to 6 December 2016), Scopus (from inception to December 2016), trials registers, and relevant web sites. We included all randomized controlled trials (RCTs) performed in adults undergoing elective primary hip replacement and comparing peripheral nerve blocks to any other pain treatment modality. We applied no language or publication status restrictions. Data were extracted independently by two review authors. We contacted study authors. We included 51 RCTs with 2793 participants; of these 45 RCTs (2491 participants: peripheral nerve block = 1288; comparators = 1203) were included in meta-analyses. There are 11 ongoing studies and three awaiting classification.Compared to systemic analgesia alone, peripheral nerve blocks reduced: pain at rest on arrival in the postoperative care unit (SMD -1.12, 95% CI -1.67 to -0.56; 9 trials, 429 participants; equivalent to 3.2 on 0 to 10 scale; moderate-quality evidence); risk of acute confusional status: risk ratio (RR) 0.10 95% CI 0.02 to 0.54; 1 trial, 225 participants; number needed to treat for additional benefit (NNTB) 12, 95% CI 11 to 22; very low-quality evidence); pruritus (RR 0.16, 95% CI 0.04 to 0.70; 2 trials, 259 participants for continuous peripheral nerve blocks; NNTB 4 (95% CI 4 to 8); very low-quality evidence); hospital length of stay (SMD -0.75, 95% CI -1.02 to -0.48; very low-quality evidence; 2 trials, 249 participants; equivalent to 0.75 day). Participant satisfaction increased (SMD 0.67, 95% CI 0.45 to 0.89; low-quality evidence; 5 trials, 363 participants; equivalent to 2.4 on 0 to 10 scale). We did not find a difference for the number of participants walking on postoperative day one (very low-quality evidence). Two nerve block-related complications were reported: one local haematoma and one delayed persistent paresis.Compared to neuraxial blocks, peripheral nerve blocks reduced the risk of pruritus (RR 0.33, 95% CI 0.19 to 0.58; 6 trials, 299 participants; moderate-quality evidence; NNTB 6 (95% CI 5 to 9). We did not find a difference for pain at rest on arrival in the postoperative care unit (moderate-quality evidence); number of nerve block-related complications (low-quality evidence); acute confusional status (very low-quality evidence); hospital length of stay (low quality-evidence); time to first walk (low-quality evidence); or participant satisfaction (high-quality evidence).We found that peripheral nerve blocks provide better pain control compared to systemic analgesia with no major differences between peripheral nerve blocks and neuraxial blocks. We also found that peripheral nerve blocks may be associated with reduced risk of postoperative acute confusional state and a modest reduction in hospital length of stay that could be meaningful in terms of cost reduction considering the increasing numbers of procedures performed annually. Compared to systemic analgesia alone, there is moderate-quality evidence that peripheral nerve blocks reduce postoperative pain, low-quality evidence that patient satisfaction is increased and very low-quality evidence for reductions in acute confusional status, pruritus and hospital length of stay .We found moderate-quality evidence that peripheral nerve blocks reduce pruritus compared with neuraxial blocks.The 11 ongoing studies, once completed, and the three studies awaiting classification may alter the conclusions of the review once assessed.

Review article: A systematic review of emergency department incident classification frameworks.

As in any part of the hospital system, safety incidents can occur in the ED. These incidents arguably have a distinct character, as the ED involves unscheduled flows of urgent patients who require disparate services. To aid understanding of safety issues and support risk management of the ED, a comparison of published ED specific incident classification frameworks was performed. A review of emergency medicine, health management and general medical publications, using Ovid SP to interrogate Medline (1976-2016) was undertaken to identify any type of taxonomy or classification-like framework for ED related incidents. These frameworks were then analysed and compared. The review identified 17 publications containing an incident classification framework. Comparison of factors and themes making up the classification constituent elements revealed some commonality, but no overall consistency, nor evolution towards an ideal framework. Inconsistency arises from differences in the evidential basis and design methodology of classifications, with design itself being an inherently subjective process. It was not possible to identify an 'ideal' incident classification framework for ED risk management, and there is significant variation in the selection of categories used by frameworks. The variation in classification could risk an unbalanced emphasis in findings through application of a particular framework. Design of an ED specific, ideal incident classification framework should be informed by a much wider range of theories of how organisations and systems work, in addition to clinical and human factors.