Articles: adult.
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Rev Bras Ter Intensiva · Mar 2009
Management of mechanical ventilation in brain injury: hyperventilation and positive end-expiratory pressure.
The study intended to make a critical review on use of pulmonary hyperventilation maneuvers and the different positive end-expiratory pressures applied to traumatic brain injury patients. As a reference were used publications in English, Spanish and Portuguese, contained in the following databases: MedLine, SciELO and LILACS, from 2000 to 2007, we included all studies about the use of pulmonary hyperventilation maneuvers and the different positive end-expiratory levels used for adult patients with brain injury at acute or chronic stage. Thirty one trials were selected, 13 about pulmonary hyperventilation, as prophylaxis, prolonged or optimized and 9 shows the levels of positive end-expiratory pressures used, ranging from 0 to 15 cmH2O. The prophylactic hyperventilation maneuver in the first 24 hours can lead to an increase of cerebral ischemia; the prolonged hyperventilation must be avoided if intracranial pressure did not increase; however optimized hyperventilation seems to be the most promising technique for control of the intracranial pressure and cerebral perfusion pressure; the rise of the positive end-expiratory pressure, up to 15cmH2O, can be applied in a conscientious form aiming to increase arterial oxygen saturation in lung injury.
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Prolonged sedation is common in mechanically ventilated patients and is associated with increased morbidity and mortality. We sought to determine the diagnostic value of head computed tomography (CT) in mechanically ventilated patients who remain unresponsive after discontinuation of sedation. ⋯ In patients on mechanical ventilation for at least 72 hours and who remain unresponsive after sedative discontinuation and with a non-focal neurologic examination, head CT is performed early and is of very limited diagnostic utility. Routine use of daily interruption of sedation is used in a minority of patients outside of a clinical trial setting though it may decrease the frequency of unresponsiveness from prolonged sedation and the need for head CT in patients mechanically ventilated for a prolonged period.
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Ont Health Technol Assess Ser · Jan 2009
Fecal occult blood test for colorectal cancer screening: an evidence-based analysis.
The colorectal cancer (CRC) screening project was undertaken by the Medical Advisory Secretariat (MAS) in collaboration with the Cancer Care Ontario (CCO).In November 2007, the Ontario Health Technology Advisory Committee (OHTAC) MAS to conduct an evidence-based analysis of the available data with respect to colorectal cancer diagnosis and prevention. The general purpose of the project was to investigate the effectiveness, cost effectiveness, and safety of the various methods and techniques used for colorectal cancer screening in average risk people, 50 years of age and older.The options currently offered for colorectal cancer screening were reviewed and five technologies were selected for review:Computed tomographic (CT) colonographyMagnetic resonance (MR) colonographyWireless capsule endoscopy (PillCam Colon)Fecal occult blood test (FOBT)Flexible sigmoidoscopyIn this review, colonoscopy was considered as the "gold standard" technique by which the effectiveness of all other modalities could be evaluated. An economic analysis was also conducted to determine cost-effectiveness of different screening modalities.Evidence-based analyses have been prepared for each of these technologies, as well as summary document that includes an economic analysis, all of which are presented at the MAS Web site: http://www.health.gov.on.ca/english/providers/program/mas/tech/techmn.html ⋯ SINGLE-TEST STUDIES: There is limited direct/indirect evidence that iFOBT has sensitivity/specificity superior to that of unrehydrated gFOBT for CRC detection: sensitivity for gFOBT:13% and 25%pooled iFOBT sensitivity:81%There is evidence that iFOBT and gFOBT have lower sensitivities for adenoma detection than for CRC detection: sensitivity for rehydrated gFOBT22%pooled iFOBT sensitivity28% REPEATED-TEST STUDIES: No trials have examined CRC mortality outcomes after repeated testing of iFOBT. Two RCTs from the United Kingdom and Denmark showed significant reduction in CRC mortality using unrehydrated gFOBT biennially Relative risk reductions of 13% (UK trial) and 16% (Danish trial); absolute difference of 0.1% (UK trial) and 0.2% (Danish trial).No significant reduction in overall mortalityInterval cancers (CRC that develop in the intervals between routine screening) UNITED KINGDOM TRIAL: 236 CRCs detected by positive test, 236 interval CRCs after negative testDANISH TRIAL: 120 CRCs detected by positive test, 146 interval CRCs after negative testUnrehydrated gFOBT has low sensitivity for CRC detection (45% in the UK trial and 54% in the Danish trial). true positive rate50% (United Kingdom and Danish RCTs)false positive rate5%-10%true negative rate90%-95% (from observational studies as RCTs did not report specificity)false negative rate50%ES Table 1:Guaiac FOBT - GRADE Quality of Evidence for InterventionsOutcomeDesignQualityConsistencyDirectnessOverall QualityCRCMortalityRCTDanishN = 137,485United KingdomN = 152,850No seriouslimitationsYes (RR reduction in 2 trials13% and 16%; absolutedifference 0.1% and 0.2%respectively).Age rangeDanish and UnitedKingdom study 45-75yearsHighCRC indicates colorectal cancer; FOBT, fecal occult blood test; GRADE, Grading of Recommendations Assessment, Development and Evaluation; RCT, randomized controlled trial.*Unlikely to be an important uncertainty.ES Table 2:GRADE Quality of Evidence for Diagnostic Tests: Implications of Testing Focusing on AccuracyNew Test and Reference TestPutative BenefitDiagnostic AccuracyPatient Outcomes and Expected Impact on ManagementSensitivitySpecificityTrue PositiveTrue NegativeFalse PositiveFalse NegativePresumed Influence on Outcomes Important to PatientsiFOBT and ColonoscopySimple, non-invasiveLessLessBenefit from diagnosis and treatment after confirmatory colonoscopySmall risk of bowel perforation during colonoscopyBenefit of reassuranceAnxiety/worry leading up to confirmatory colonoscopySmall risk of bowel perforation during confirmatory colonoscopyDetriment from delayed diagnosisDirectness of Evidence (Test Results) for Outcomes Important to PatientsSome uncertainty (until after confirmatory colonoscopy)No UncertaintyUncertaintyUncertaintyFOBT indicates fecal occult blood test; GRADE, Grading of Recommendations Assessment, Development and Evaluation.Es Table 3:Immunochemical FOBT - GRADE Quality of Evidence for Diagnostic StudiesNo. ofStudiesDesignLimitationsIndirectnessInconsistencyImprecise dataQuality6Diagnostic cohort (single test)(reference standard for positive and negative iFOBT results was colonoscopy)No serious limitationsTP Some uncertaintyTN No uncertaintyFP UncertaintyFN UncertaintyTP rate = 69%TN rate = 94%FP rate = 6%FN rate = 30%(from direct comparison study)Diagnostic cohort iFOBT sensitivities: 50% to 90%High I(2)in pooled sensitivity and specificityWide range in confidence intervals in direct comparison studyLow*FN indicates false negative; FOBT, fecal occult blood test; FP, false positive; Development and Evaluation; TN, true negative; TP, true positive.*Uncertainty until after confirmatory colonoscopy†Stress/worry for patient until confirmatory colonoscopy‡Detrimental effects due to delayed diagnosis.§For these 3 reasons, downgrade quality from High to Moderate.║For these 3 reasons, downgrade quality from Moderate to Low. CONSIDERATIONS FOR THE ONTARIO HEALTH SYSTEM: Executive Summary Table 4 shows the potential system pressures and benefit/risk analysis for the use of FOBT and colonoscopy to screen for CRC in average-risk adults, ages 50 and over in Ontario. Es Table 4:Summary of Potential System Pressures for FOBT ScreeningCriterionColonoscopyFOBTPrimarily prevent or detect cancer?Prevent and detectDetectFrequency of screeningEvery 10 yearsMust repeat at regular intervalsEvery 2 yearsMust repeat at regular intervalsLevel of evidenceObservational studiesRCTsBenefitsUsed as gold standard in studiesINTERVENTION GRADE QUALITY: High (gFOBT)DIAGNOSTIC GRADE QUALITY: Low (iFOBT)No RCTs examining the effectiveness of repeated iFOBT on CRC mortality reduction were identifiedLimited direct/indirect evidence that iFOBT has superior sensitivity/specificity to unrehydrated gFOBT for detection of CRCRisks0.1% risk of serious bleeding and perforation requiring surgery0.3% risk of serious complications (stroke/bleeding requiring hospitalization/ myocardial infarction)High interval cancer rateThe small benefit in CRC mortality reduction (absolute difference 0.1% to 0.2%) also coincides with a 0.3% risk of serious complications.Preparation requirementsNo food 1 day prior to examOffice/hospital visitComplete bowel preparationSedationEliminate citrus fruit and juices and vitamin C from diet for 3 days prior to/during stool collection.Person applies 2 samples per bowel movement (each occurring on 3 different days) onto test areas of FOBT cards.Resources required for screening asymptomatic, average-risk adults ≥ 50 yearsIncreased demand for colonoscopies and colonoscopists or nurses who perform colonoscopies. 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Ont Health Technol Assess Ser · Jan 2009
Oral appliances for obstructive sleep apnea: an evidence-based analysis.
The objective of this review was to determine the clinical effectiveness of oral appliances compared to 'no treatment', continuous positive airway pressure (CPAP), or surgery for the management of obstructive sleep apnea (OSA). ⋯ Obstructive sleep apnea, oral appliances, mandibular advancement splints, tongue repositioning devices.
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Stud Health Technol Inform · Jan 2009
Scientific evidence for the effectiveness of virtual reality for pain reduction in adults with acute or chronic pain.
The objective of this systematic review was to determine the level of scientific evidence for the effectiveness of VR for pain management in adults with pain. A comprehensive systematic search involving major health care databases was undertaken to identify randomized clinical trials (RCTs) and descriptive studies. Twenty-seven studies were identified that fulfilled the inclusion criteria. ⋯ Moreover, there is limited evidence (Level 2a) of effectiveness of immersive VR compared to no VR for reducing chronic pain. There is currently no published study that has explored the effectiveness of non-immersive VR for chronic pain (level 5). It is concluded that VR can be recommended as a standard or adjunct clinical intervention for pain management at least in the management of acute pain.