Glycaemic control for patients with severe acute brain injury: Protocol for a systematic review

Background

Hyperglycaemia is common in patients with acute brain injury admitted to an intensive care unit (ICU). Many studies have found associations between development of hyperglycaemia and increased mortality in hospitalised patients. However, the optimal target for blood glucose control is unknown. We want to conduct a systematic review with meta-analysis and trial sequential analysis to explore the beneficial and harmful effects of restrictive versus liberal glucose control on patient outcomes in adults with severe acute brain injury.

Methods

We will systematically search medical databases including CENTRAL, Embase, MEDLINE and trial registries. We will search the following websites for ongoing or unpublished trials: http://www.controlled-trials.com/ , http://www.clinicaltrials.gov/ , www.eudraCT.com , http://centerwatch.com/ , The Cochrane Library's CENTRAL, PubMed, EMBASE, Science Citation Index Expanded and CINAHL. Two authors will independently review and select trials and extract data. We will include randomised trials comparing levels of glucose control in our analyses and observational studies will be included to address potential harms. The primary outcomes are defined as all-cause mortality, functional outcome and health-related quality of life. Secondary outcomes include serious adverse events including hypoglycaemia, length of ICU stay and duration of mechanical ventilation, and explorative outcomes including intracranial pressure and infection. Trial Sequential Analysis will be used to investigate the risk of type I error due to repetitive testing and to further explore imprecision. Quality of trials will be evaluated using the Cochrane Risk of Bias tool, and quality of evidence will be assessed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach.

Discussion

The results of the systematic review will be disseminated through peer-reviewed publication. With the review, we hope to inform future randomised clinical trials and improve clinical practice.     

Sex Disparities in Risk of Mortality Among Children With ESRD

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Lack of efficacy of thickened feeding as treatment for gastroesophageal reflux

The efficacy of thickened feedings for the treatment of gastroesophageal reflux in infancy was evaluated. Fifty-two infants were examined with prolonged pH monitoring of the distal esophagus after feedings of apple juice or apple juice thickened with rice cereal. All infants had a minimum of three feedings of both thickened and unthickened juice. The recordings of distal esophageal pH were analyzed for the percent of time the pH was less than 4 in the first 2 hours after each feeding. The infants were maintained in the following positions after feeding: prone (n = 29), prone-board with the head elevated 30 degrees from horizontal (n = 29), supine (n = 7), and unrestricted (n = 21). We found no significant difference in the percent of time with reflux with thickened versus unthickened feedings except in those infants maintained in the 30-degree prone position. In the first 2 hours after eating thickened juice, infants maintained in this position had increased esophageal reflux time (P less than 0.006). Further analysis revealed that 33% of the infants had a greater than 30% increase in esophageal reflux time after thickened feedings. Our study suggests that the immediate effect of thickened feedings on gastroesophageal reflux in infants is unpredictable.     

Ingestion of immune bloodmeals and infection of Aedes fowleri, Aedes mcintoshi, and Culex pipiens with Rift Valley fever virus

Rift Valley fever (RVF) virus infection, dissemination, and transmission rates were determined for Aedes fowleri, Aedes mcintoshi and Culex pipiens 7 or 10 days after sequentially feeding to repletion on RVF virus immune hamsters and RVF viremic hamsters, or after feeding on a mixture of RVF virus immune sheep serum and RVF viremic hamster blood through a pledget. No significant differences in infection or dissemination rates were detected among Ae. fowleri and Cx. pipiens feeding to repletion on immune hamsters before or after feeding to repletion on a viremic hamster. Similarly, no significant differences in infection, dissemination, or transmission rates were observed among Ae. fowleri and Cx. pipiens feeding to repletion on immune hamsters or nonimmune (control) hamsters 0 or 24 hr after inoculation with RVF virus. Infection rates were significantly higher for Ae. fowleri (56/66, 85%) and Cx. pipiens (123/148, 83%) fed only on viremic hamsters than for those interrupted to complete feeding on an immune hamster (Ae. fowleri [24/49, 59%], Cx. pipiens [66/131, 50%]) or a nonimmune hamster (Ae. fowleri [32/51, 63%], Cx. pipiens [69/127, 54%]). However, no significant differences were detected in infection, dissemination, or transmission rates among Ae. fowleri, Ae. mcintoshi or Cx. pipiens fed on a viremic hamster and interrupted to complete feeding on an immune vs. a nonimmune hamster. Results from interrupted feeding experiments were significantly different from pledget feeding experiments.(ABSTRACT TRUNCATED AT 250 WORDS)