Turning Research Into Practice Research Articles

Clinical practice guidelines for the diagnosis and management of Duchenne muscular dystrophy: a scoping review.

Our objective was to identify recent CPGs for the diagnosis and management of DMD and summarize their characteristics and reliability. We conducted a scoping review of CPGs using MEDLINE, the Turning Research Into Practice (TRIP) database, Google Scholar, guidelines created by organizations, and other repositories to identify CPGs published in the last 5 years. Our protocol was drafted using the Preferred Reporting Items for Systematic Reviews and Meta-analyses for scoping reviews. To assess the reliability of the CPGs, we used all the domains included in the Appraisal of Guidelines Research and Evaluation II. We selected three CPGs published or updated between 2015 and 2020. All the guidelines showed good or adequate methodological rigor but presented pitfalls in stakeholder involvement and applicability domains. Recommendations were coherent across CPGs on steroid treatment, except for minor differences in dosing regimens. However, the recommendations were different for new drugs. There is a need for current and reliable CPGs that develop broad topics on the management of DMD and consider the challenges of developing recommendations for RDs.

Serological screening for cytomegalovirus during pregnancy: A systematic review of clinical practice guidelines and consensus statements.

Congenital cytomegalovirus (cCMV) is the most common congenital infection worldwide. cCMV can lead to severe long-term sequelae, including neurological impairment and developmental delay. We performed a systematic review of clinical practice guidelines containing recommendations concerning serological screening for CMV during pregnancy. We performed a search of MEDLINE, Turning Research into Practice (TRIP) database and the grey literature for clinical practice guidelines or consensus statements published in the English language from Jan 2010 to June 2022. The quality of the included guidelines was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. Textual synthesis was used to summarise and compare the recommendations on CMV serological screening in pregnancy. Eleven guidelines and two consensus statements were included. None recommended universal serological screening for CMV in pregnant women; five recommended screening for high-risk women (those with frequent contact with young children). The overall quality of the guidelines varied; most were medium or low. Although clinical practice guidelines do not actively recommend routine serological screening in pregnancy, most did not meet standard processes for development and predated the emerging data on valaciclovir as a potential intervention. Existing recommendations are underpinned by limited, low-level evidence, exposing the lack of robust data in this area of practice. Further high-level evidence and methodologically robust guidelines are needed to guide clinical practice in this rapidly changing field.

Oral Microbiome as a Tool of Systemic Disease on Cleft Patients: A New Landscape.

The oral cavity microbiome comprises benign and pathogenic bacteria, with more than 700 species identified. However, the current literature regarding resident bacterial flora in the oropharyngeal cavities in cleft lip/palate (CLP) patients still needs to be completed. This review aims to evaluate the role of the oral microbiome of cleft patients as an indicator in systemic diseases for which cleft patients might be at higher risk in the short or long term. A literature review was performed in July 2020 using Biomedical Reference Collection Comprehensive, Cumulative Index to Nursing and Allied Health Literature (CINAHL) Complete, Dentistry & Oral Sciences Source via Elton B. Stephens Company/Online Database (EBSCO), Turning Research into Practice (TRIP), and PubMed. The keywords used were "oral, bacteria, microbiome, biota, flora, cleft, palate." The resulting 466 articles were deduplicated using Endnote. The total amount of articles' abstracts without duplicates was filtered using a set criterion. The title and abstract filter criteria included 1) cleft lip (CL) and/or cleft palate (CP) patients, 2) changes in the oral microbiome in CL and/or CP patients, 3) male and female patients 0-21 years old, and 4) English language. The full-text filter criteria included 1) CL and/or CP patients vs. non-cleft control patients, 2) oral bacteria, 3) nonprocedural measurements of microorganisms, and 4) case-control studies. A Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) flow chart was created using the EndNote data results. The final five articles of the systematic search indicated that the oral cavity of cleft lip and/or palate patients resulted in 1) contradicting levels of Streptococcus mitis and Streptococcus salivarius; 2) lower levels of Streptococcus gordonii, Bordetella dentium, Fusobacterium nucleatum, Veillonella parvula, Bacillus and Lautropia when compared to the control group; 3) higher levels of Staphylococcus epidermidis and Methicillin-sensitive Staphylococcus aureus compared to the control group; 4) presence of Enterobacter cloacae 36.6%, Klebsiella pneumoni 53.3%, and Klebsiella oxytoca 76.6%vs. absence in the control non-cleft group. Patients with CL and/or CP are at higher risk for caries, periodontal diseases, and upper and lower respiratory infections. The results from this review indicate that relative levels of certain bacteria may be associated with these issues. The lower levels of S. mitis, S. salivarius, S. gordini, and F. nucleatum in the oral cavity of cleft patients could be linked as a possible cause of the higher incidence of tooth decay, gingivitis and periodontal disease as high levels of these bacteria are associated with oral disease. Further, the higher incidence of sinusitis in cleft patients might be linked to low levels of S. salivarius in the oral profile of these patients. Likewise, E. cloacae, K. oxycota, and K. pneumoni have been linked with pneumonia and bronchiolitis, both of which are increased in cleft patients. The oral bacterial dysbiosis of cleft patients observed in this review may play a vital function in the oral microbiome's diversity, which could play a role in disease progression and disease markers. The pattern seen in cleft patients potentially demonstrates how structural abnormalities can lead to the onset of severe infection.

Prognosticating Acute Ischemic Stroke and Estimating the Feasibility of Mapping Stroke Volume to the Functional Outcomes Using Diffusion-Weighted Images: A Systematic Review Protocol.

Diffusion-weighted image or DWI is commonly used to provide valuable and diverse information on acute stroke in tertiary care hospitals. DWI is a sensitive and accurate method for identifying the infarct core and can expose the area of cerebral infarction within a few hours of onset. This systematic review is planned to evaluate the measurement of stroke volume on DWI and correlate it with functional outcomes (modified ranking scale). We have adhered to the PRISMA-P checklist to report this systematic review protocol. PubMed, Web of Science, Scopus, and TRIP (Turning Research into Practice) databases will be searched. Two independent reviewers will screen the records, extract data, and critically appraise the studies. A checklist for critical appraisal will be applied for data abstraction, and data extraction will be done using predictive modeling for systematic reviews. The risk of bias will be measured by the Prediction Model Risk of Bias Assessment Tool (PROBAST). The meta-analysis will be considered only if included studies have adequate data, and STATA statistical package version 13.1 will be used for performing a meta-analysis. A narrative synthesis will be performed if meta-analysis is not possible. As this review will focus on secondary information, there is no ethical consideration required. We will disseminate our findings by publishing our analysis in a peer-reviewed journal. In Prospective Register of Systematic Reviews (CRD42019141840).

Assessment of the quality and content of clinical practice guidelines (CPGs) for vitamin D and for immigrants using the AGREE-II instrument: a protocol for systematic review

IntroductionWorldwide, more immigrants experience vitamin D (vitD) deficiency than non-immigrants, which is attributed to ethnic variations, place or region of birth, skin pigmentation, clothing style, and resettlement-related changes in diet, physical activity, and sun exposure. Current recommendations in clinical practice guidelines (CPGs) concerning vitD are inadequate to address vitD deficiency among immigrants. CPGs may also lack guidance for physicians on vitD supplementation for immigrants. Moreover, there are concerns about the overall quality of these CPGs.ObjectivesThis systematic review will collate and critically appraise CPGs relevant to immigrants’ health and vitD. Moreover, we will evaluate whether the CPGs of vitD including recommendations for immigrants and clarify whether the CPGs of immigrants include recommendations on vitD.MethodsA systematic search of Ovid MEDLINE® ALL, EMBASE, and Turning Research Into Practice (TRIP) electronic databases, guideline repositories, and gray literature will be conducted to identify relevant CPGs. Two reviewers will independently evaluate the methodological quality of the retrieved guidelines using the Appraisal of Guidelines, Research, and Evaluation-II (AGREE-II) instrument. CPGs scoring ≥60% in at least four domains, including “rigor of development,” will be considered high quality.ConclusionEvaluating the quality and content of relevant CPGs may support researchers in developing national and global guidelines for immigrants. Furthermore, it may support vitD testing, nutritional counseling, and supplementation for vulnerable immigrant sub-populations.Systematic review registrationPROSPERO CRD42021240562.

Preparing for pandemics: a systematic review of pandemic influenza clinical management guidelines

BackgroundThe COVID-19 pandemic has highlighted the importance of evidence-based clinical decision-making. Clinical management guidelines (CMGs) may help reduce morbidity and mortality by improving the quality of clinical decisions. This systematic review aims to evaluate the availability, inclusivity, and quality of pandemic influenza CMGs, to identify gaps that can be addressed to strengthen pandemic preparedness in this area.MethodsOvid Medline, Ovid Embase, TRIP (Turning Research Into Practice), and Guideline Central were searched systematically from January 2008 to 23rd June 2022, complemented by a grey literature search till 16th June 2022. Pandemic influenza CMGs including supportive care or empirical treatment recommendations were included. Two reviewers independently extracted data from the included studies and assessed their quality using AGREE II (Appraisal of Guidelines for Research & Evaluation). The findings are presented narratively.ResultsForty-eight CMGs were included. They were produced in high- (42%, 20/48), upper-middle- (40%, 19/48), and lower-middle (8%, 4/48) income countries, or by international organisations (10%, 5/48). Most CMGs (81%, 39/48) were over 5 years old. Guidelines included treatment recommendations for children (75%, 36/48), pregnant women (54%, 26/48), people with immunosuppression (33%, 16/48), and older adults (29%, 14/48). Many CMGs were of low quality (median overall score: 3 out of 7 (range 1–7). All recommended oseltamivir; recommendations for other neuraminidase inhibitors and supportive care were limited and at times contradictory. Only 56% (27/48) and 27% (13/48) addressed oxygen and fluid therapy, respectively.ConclusionsOur data highlights the limited availability of up-to-date pandemic influenza CMGs globally. Of those identified, many were limited in scope and quality and several lacked recommendations for specific at-risk populations. Recommendations on supportive care, the mainstay of treatment, were limited and heterogeneous. The most recent guideline highlighted that the evidence-base to support antiviral treatment recommendations is still limited. There is an urgent need for trials into treatment and supportive care strategies including for different risk populations. New evidence should be incorporated into globally accessible guidelines, to benefit patient outcomes. A ‘living guideline’ framework is recommended and further research into guideline implementation in different resourced settings, particularly low- and middle-income countries.

Lactoferrin reduces the risk of respiratory tract infections: A meta-analysis of randomized controlled trials

Lactoferrin (Lf) is one of the key immunomodulatory substances found naturally in various body fluids, such as saliva, tears, and breast milk, and forms a vital part of the innate defense against invading pathogens. Various studies have demonstrated antibacterial, antifungal, and antiviral properties of Lf and its protective role against respiratory tract infections (RTIs). The present meta-analysis aims to elucidate the association of Lf administration in reducing the risk of RTIs by systematically reviewing the data from randomized controlled trials (RCTs). We systematically searched PubMed, Cochrane Library, Medline & CINAHL, Turning Research into Practice (TRIP), ProQuest Theses & Dissertations Databases, and China National Knowledge Infrastructure (CNKI) from inception till March 15, 2021. The primary outcome measure was a reduction in respiratory illness; decrease in frequency, symptoms, and duration. Random-effects model was used to estimate the odds ratio (OR) and 95% confidence interval (CI). We used Cochrane's RoB-2 to appraise the risk of bias of included RCTs. A total of nine RCTs were eligible for this review, of which six were included in the meta-analysis. Overall, two studies demonstrated a high risk of bias. The meta-analysis revealed a significantly reduced odds of developing respiratory infections with the use of Lf relative to the control (pooled odds ratio=0.57; 95% confidence interval 0.44 to 0.74, n=1,194), with sufficient evidence against the hypothesis of 'no significant difference' at the current sample size. The administration of Lf shows promising efficacy in reducing the risk of RTIs. Current evidence also favours Lf fortification of infant formula. Lf may also have a beneficial role in managing symptoms and recovery of patients suffering from RTIs and may have potential for use as an adjunct in COVID-19, however this warrants further evidence from a large well-designed RCT.

Prescribing cascades in community-dwelling adults: protocol for a systematic review.

Introduction: Internationally, health systems face the challenge of managing a growing ageing population living with multimorbidity and polypharmacy. Potentially inappropriate prescribing is common among patients with polypharmacy, increasing the risk for adverse drug reactions (ADRs). Several prescribing indicator sets exist to improve prescribing and reduce potentially inappropriate prescribing, but do not address prescribing cascades. Prescribing cascades occur when a medication is prescribed to treat an ADR to another prescribed medication, whether intentionally or unintentionally, and constitute an important area to consider when characterising problematic polypharmacy. This is a protocol for a systematic review examining prescribing cascades in community-dwelling adults. Methods: The review will be reported adhering to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A systematic search of Medline (Ovid), EMBASE, PsycINFO, CINAHL and the Cochrane Library will be conducted from inception to March 2021, using a predetermined strategy. Grey literature will be searched using Open Grey, MedNar, Dart Europe, and the Turning Research Into Practice (TRIP) databases. No restrictions will be placed on language or publication year. Inclusion criteria are: population - community-dwelling adults (≥18 years); risk - prescription medication with the potential to cause side effects; outcomes - initiation of a new medicine to 'treat' or reduce the risk of experiencing an ADR. Prospective and retrospective cohort studies, case control and case series studies will be included. Two reviewers will independently screen titles and abstracts; studies meeting inclusion criteria will undergo independent full-text screening by two reviewers. A narrative synthesis will be conducted. Study quality will be independently assessed using the relevant Joanna Briggs Institute Critical Appraisal Checklist. Discussion: This systematic review will identify examples of prescribing cascades for community-dwelling adults and contribute to developing an evidence base regarding such cascades. Registration: PROSPERO [ CRD42021243163, 31/03/2021].

Prescribing cascades in community-dwelling adults: protocol for a systematic review

Introduction: Internationally, health systems face the challenge of managing a growing ageing population living with multimorbidity and polypharmacy. Potentially inappropriate prescribing is common among patients with polypharmacy, increasing the risk for adverse drug reactions (ADRs). Several prescribing indicator sets exist to improve prescribing and reduce potentially inappropriate prescribing, but do not address prescribing cascades. Prescribing cascades occur when a medication is prescribed to treat an ADR to another prescribed medication, whether intentionally or unintentionally, and constitute an important area to consider when characterising problematic polypharmacy. This is a protocol for a systematic review examining prescribing cascades in community-dwelling adults. Methods: The review will be reported adhering to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A systematic search of Medline (Ovid), EMBASE, PsycINFO, CINAHL and the Cochrane Library will be conducted from inception to March 2021, using a predetermined strategy. Grey literature will be searched using Open Grey, MedNar, Dart Europe, and the Turning Research Into Practice (TRIP) databases. No restrictions will be placed on language or publication year. Inclusion criteria are: population - community-dwelling adults (≥18 years); risk - prescription medication with the potential to cause side effects; outcomes - initiation of a new medicine to ‘treat’ or reduce the risk of experiencing an ADR. Prospective and retrospective cohort studies, case control and case series studies will be included. Two reviewers will independently screen titles and abstracts; studies meeting inclusion criteria will undergo independent full-text screening by two reviewers. A narrative synthesis will be conducted. Study quality will be independently assessed using the relevant Joanna Briggs Institute Critical Appraisal Checklist. Discussion: This systematic review will identify examples of prescribing cascades for community-dwelling adults and contribute to developing an evidence base regarding such cascades. Registration: PROSPERO [ CRD42021243163, 31/03/2021].

Prescribing cascades in community-dwelling adults: protocol for a systematic review

Introduction: Internationally, health systems face the challenge of managing a growing ageing population living with multimorbidity and polypharmacy. Potentially inappropriate prescribing is common among patients with polypharmacy, increasing the risk for adverse drug reactions (ADRs). Several prescribing indicator sets exist to improve prescribing and reduce potentially inappropriate prescribing, but do not address prescribing cascades. Prescribing cascades occur when a medication is prescribed to treat an ADR to another prescribed medication, whether intentionally or unintentionally, and constitute an important area to consider when characterising problematic polypharmacy. This is a protocol for a systematic review examining prescribing cascades in community-dwelling adults. Methods: The review will be reported adhering to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. A systematic search of Medline (Ovid), EMBASE, PsycINFO, CINAHL and the Cochrane Library will be conducted from inception to March 2021, using a predetermined strategy. Grey literature will be searched using Open Grey, MedNar, Dart Europe, and the Turning Research Into Practice (TRIP) databases. No restrictions will be placed on language or publication year. Inclusion criteria are: population - community-dwelling adults (≥18 years), including those in residential or nursing homes; risk - prescription medication with the potential to cause side effects; outcomes - initiation of a new medicine to ‘treat’ or reduce the risk of experiencing an ADR. Prospective and retrospective cohort studies, case control and case series studies will be included. Two reviewers will independently screen titles and abstracts; studies meeting inclusion criteria will undergo independent full-text screening by two reviewers. A narrative synthesis will be conducted. Study quality will be independently assessed using the relevant Joanna Briggs Institute Critical Appraisal Checklist. Discussion: This systematic review will identify examples of prescribing cascades for community-dwelling adults and contribute to developing an evidence base regarding such cascades. Registration: PROSPERO [CRD42021243163, 31/03/2021].

Evaluation of the Nasolabial Angle in Orthodontic Diagnosis: A Systematic Review

Background: This study is a systematic literature review aiming at identifying the variation of the average nasolabial angle (NLA) in various orthodontic situations. The NLA is one of the key factors to be studied in an orthodontic diagnosis for the aesthetics of the nose and facial profile. Methods: Out of 3118 articles resulting from four search engines (PubMed, Cochrane Library, Turning Research Into Practice (TRIP) and SciELO), the final study allowed the analysis and comparison of only 26 studies. These included studies have considered the NLA in the following cases: teeth extraction, class II malocclusion, class III malocclusion, rapid palatal expansion (RPE), orthognathic surgery, and non-surgical rhinoplasty with a hyaluronic acid filler. Results: The results indicate that teeth extraction and the use of hyaluronic acid fillers significantly affect the NLA. Conclusions: This systematic review shows that a statistically significant change in NLA values occurs in: extractive treatments of all four of the first or second premolars in class I patients; in class II patients with upper maxillary protrusion; in patients with maxillary biprotrusion, except for cases of severe crowding; and in patients undergoing non-surgical rhinoplasty with a hyaluronic acid filler. Trial registration number: PROSPERO CRD42020185166

Effectiveness of ivermectin for COVID-19: A systematic review

OBJECTIVE: To evaluate the efficacy and safety of ivermectin in the prevention and treatment of COVID-19. METHODS: This is a systematic review of randomized clinical trials. We searched the electronic databases PubMed (1966-2021), EMBASE (1974-2021) and Clinical Trials (2021) and two evidence megabusers: Turning Research Into Practice (TRIP) database (2021) and Epstemonikos (2021). There was no geographic or language restriction, using DeCS descriptors and terms (Health Sciences Descriptors). The synthesis method involved the combination of similar studies in a narrative review. RESULTS: 463 citations were identified, and 2 studies were included, following the inclusion and exclusion criteria. Both studies showed very low quality and reduced sampling. CONCLUSION: The studies completed and published to date do not support the use of ivermectin in the prevention or treatment of COVID-19. It is suggested to carry out new quality clinical trials to elucidate the issue.

Using Telemedicine to Reduce Suicide Ideation and Behavior: A Systematic Literature Review

Objective: To review the published research for reported effectiveness of telemedicine in reducing suicide ideation and behavior in patients already diagnosed with a psychiatric disorder. Design: A thorough literature search on the PubMed, Web of Science, PsycInfo, Cochrane Library, and TRIP (Turning Research Into Practice) Medical Database was conducted. Phrases such as “telemedicine,” “telehealth,” “remote consultation,” “mobile health,” “psychiatric disorders,” “suicide,” “suicide, attempted or ideation,” and “telepsychiatry” were employed in a variety of combinations. The primary inclusion criteria encompassed peer-reviewed articles published in the past 5 years. Secondary inclusion criteria comprised: (1) the diagnosis of any psychiatric disorder for all patients included in the study, (2) the absence or presence of use of telepsychiatry to offer consultation and communication, and (3) reported outcomes involving suicide rates or attempted suicide rates. The research publications passing inclusion criteria were assessed, and all their corresponding outcome measures were included in a meta-analysis. Results: A total of 705 studies were identified by applying the initial search strategy to the electronic databases described. Of these, 205 passed the primary inclusion criteria. After excluding duplicates and non-English articles, 105 articles were screened using the secondary inclusion criteria. Nine articles remained, including three systematic reviews that were excluded. Finally, a total of six independent, non-overlapping studies were included in this meta-analysis, encompassing data for 576 participants. The 18 outcome measures in this meta-analysis included five “positive” measures: perceived ability to cope with suicidal ideation, optimism, gratitude, positive affect, and the Mini Mental State Exam. The “negative” measures included: suicidal ideation intensity, hopelessness, depression, suicidality, HAMD (Hamilton Depression Rating Scale) score, HAMD score without suicide item, medical admissions, number of days of medical hospitalizations, number of psychiatric hospitalizations, number of emergency room visits, suicide ideation questionnaire (SIQ) from baseline to posttreatment, and SIQ from baseline to follow-up. Overall, this review found support for the hypothesis that telemedicine can reduce suicide ideation and behavior. There was a moderate effect size for the 18 measures analyzed. Based on the four different forest plots presented in this analysis, all average effect sizes calculated showed that the intervention of telemedicine has a small-to-moderate effect on the measures studied, which translates loosely to a small-to-moderate effect on the patient’s suicide ideation and behavior. Conclusions: Telemedicine appears to be a promising way to reduce suicidal ideation, although how this translates into reductions in self-harm and/or suicide attempts is unclear from this review alone.

Content, Structure, and Delivery Characteristics of Yoga Interventions for Managing Hypertension: A Systematic Review Protocol.

Aims:This systematic review aims to summarize the content, structure, and delivery characteristics of yoga interventions used for managing hypertension.Introduction:Globally, hypertension-related morbidity and mortality are high. Yoga might be a potential solution for managing hypertension. Several systematic reviews have evaluated the effectiveness of yoga interventions for managing hypertension. There is a need to summarize the content, structure, and delivery characteristics of yoga interventions used for managing hypertension.Inclusion Criteria:Randomized controlled trials assessing the effectiveness of yoga interventions for managing hypertension in adults and reporting either the content, structure, or delivery characteristics will be included in this systematic review.Methods:The Joanna Briggs Institute systematic review methodology will be followed to conduct the review. We aim to search for a wide range of sources to find both published and unpublished studies. The following databases will be searched: MEDLINE, Embase, CINAHL, PsycINFO, Allied and Complementary Medicine (AMED), Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), Turning Research Into Practice (TRIP), AYUSH Research Portal, A Bibliography of Indian Medicine (ABIM), Digital Helpline for Ayurveda Research Articles (DHARA), CAM-QUEST, and Directory of Open Access Journals (DOAJ). The search for unpublished studies will include OpenGrey, EThOS, and ProQuest Dissertations and Theses. Databases will be searched from their inception dates, and no language restrictions will be applied. A narrative description of the findings will be written, structured around the aims of this systematic review.Systematic review registration number:CRD42019139404

Cerumen Management: An Updated Clinical Review and Evidence-Based Approach for Primary Care Physicians.

Objective: To provide family physicians with a practical, evidence-based approach to managing patients with cerumen impaction. Methods: MEDLINE, The Cochrane Library, and the Turning Research Into Practice (TRIP) database were searched for English-language cerumen impaction guidelines and reviews. All such articles published between 1992 and 2018 were reviewed, with most providing level II and III evidence. Results: Cerumen impaction is a common presentation seen in primary care and cerumen removal is one of the most common otolaryngologic procedures performed in general practice. Cerumen impaction is often harmless but can be accompanied by more serious symptoms. Cerumenolytics and irrigation of the ear canal are reasonable first-line therapies and can be used in conjunction or isolation. If irrigation and cerumenolytics are contraindicated, manual removal is appropriate, but the tools necessary are not commonplace in primary care clinics and specialized training may be required to prevent adverse outcomes. Conclusion: Family physicians play a key role in the assessment and management of cerumen impaction and are well equipped to do so. Knowledge of the available techniques for cerumen removal as well as their contraindications ensures that cerumen is removed safely and effectively. When cerumen removal cannot be removed safely in a primary care setting, referral to Otolaryngology-Head and Neck Surgery is appropriate.

Early enteral nutrition (within 48 hours) versus delayed enteral nutrition (after 48 hours) with or without supplemental parenteral nutrition in critically ill adults

Early enteral nutrition support (within 48 hours of admission or injury) is frequently recommended for the management of patients in intensive care units (ICU). Early enteral nutrition is recommended in many clinical practice guidelines, although there appears to be a lack of evidence for its use and benefit. To evaluate the efficacy and safety of early enteral nutrition (initiated within 48 hours of initial injury or ICU admission) versus delayed enteral nutrition (initiated later than 48 hours after initial injury or ICU admission), with or without supplemental parenteral nutrition, in critically ill adults. We searched CENTRAL (2019, Issue 4), MEDLINE Ovid (1946 to April 2019), Embase Ovid SP (1974 to April 2019), CINAHL EBSCO (1982 to April 2019), and ISI Web of Science (1945 to April 2019). We also searched Turning Research Into Practice (TRIP), trial registers (ClinicalTrials.gov, ISRCTN registry), and scientific conference reports, including the American Society for Parenteral and Enteral Nutrition and the European Society for Clinical Nutrition and Metabolism. We applied no restrictions by language or publication status. We included all randomized controlled trials (RCTs) that compared early versus delayed enteral nutrition, with or without supplemental parenteral nutrition, in adults who were in the ICU for longer than 72 hours. This includedindividuals admitted for medical, surgical, and trauma diagnoses, and who required any type of enteral nutrition. Two review authors extracted study data and assessed the risk of bias in the included studies. We expressed results as risk ratios (RR) for dichotomous data, and as mean differences (MD) for continuous data, both with 95% confidence intervals (CI). We assessed the certainty of the evidence using GRADE. We included seven RCTs with a total of 345 participants. Outcome data were limited, and we judged many trials to have an unclear risk of bias in several domains. Early versus delayed enteral nutrition Six trials (318 participants) assessed early versus delayed enteral nutrition in general, medical, and trauma ICUs in the USA, Australia, Greece, India, and Russia. Primary outcomes Five studies (259 participants) measured mortality. It is uncertain whether early enteral nutrition affects the risk of mortality within 30 days (RR 1.00, 95% CI 0.16 to 6.38; 1 study, 38 participants; very low-quality evidence). Four studies (221 participants) reported mortality without describing the timeframe; we did not pool these results. None of the studies reported a clear difference in mortality between groups. Three studies (156 participants) reported infectious complications. We were unable to pool the results due to unreported data and substantial clinical heterogeneity. The results were inconsistent across studies. One trial measured feed intolerance or gastrointestinal complications; it is uncertain whether early enteral nutrition affects this outcome (RR 0.84, 95% CI 0.35 to 2.01; 59 participants; very low-quality evidence). Secondary outcomes One trial assessed hospital length of stay and reported a longer stay in the early enteral group (median 15 days (interquartile range (IQR) 9.5 to 20) versus 12 days (IQR 7.5 to15); P = 0.05; 59 participants; very low-quality evidence). Three studies (125 participants) reported the duration of mechanical ventilation. We did not pool the results due to clinical and statistical heterogeneity. The results were inconsistent across studies. It is uncertain whether early enteral nutrition affects the risk of pneumonia (RR 0.77, 95% CI 0.55 to 1.06; 4 studies, 192 participants; very low-quality evidence). Early enteral nutrition with supplemental parenteral nutrition versus delayed enteral nutrition with supplemental parenteral nutrition We identified one trial in a burn ICU in the USA (27 participants). Primary outcomes It is uncertain whether early enteral nutrition with supplemental parenteral nutrition affects the risk of mortality (RR 0.74, 95% CI 0.25 to 2.18; very low-quality evidence), or infectious complications (MD 0.00, 95% CI -1.94 to 1.94; very low-quality evidence). There were no data available for feed intolerance or gastrointestinal complications. Secondary outcomes It is uncertain whether early enteral nutrition with supplemental parenteral nutrition reduces the duration of mechanical ventilation (MD 9.00, 95% CI -10.99 to 28.99; very low-quality evidence). There were no data available for hospital length of stay or pneumonia. Due to very low-quality evidence, we are uncertain whether early enteral nutrition, compared with delayed enteral nutrition, affects the risk of mortality within 30 days, feed intolerance or gastrointestinal complications, or pneumonia. Due to very low-quality evidence, we are uncertain if early enteral nutrition with supplemental parenteral nutrition compared with delayed enteral nutrition with supplemental parenteral nutrition reduces mortality, infectious complications, or duration of mechanical ventilation. There is currently insufficient evidence; there is a need for large, multicentred studies with rigorous methodology, which measure important clinical outcomes.

Interventions to prevent aggression against doctors: a systematic review

ObjectiveTo find out if there is evidence on interventions to prevent aggression against doctors.DesignThis systematic review searched the literature and reported in accordance with Preferred Reporting Items for Systematic Reviews...

TRIP Database

Based in the United Kingdom, TRIP (Turning Research Into Practice) is a clinical research database that allows users to search across multiple sources of information and publication types using a single interface.

Welfare-to-work interventions and their effects on the mental and physical health of lone parents and their children.

Welfare-to-work interventions and their effects on the mental and physical health of lone parents and their children.

Direct-acting antivirals for chronic hepatitis C.

Direct-acting antivirals for chronic hepatitis C.