Rationale: Sepsis and septic shock are associated with microcirculatory dysfunction, which is believed to contribute to sepsis-induced organ failure. Vasodilators have been proposed to improve tissue perfusion in sepsis, but the overall survival impact of this strategy is unclear. Objectives: To evaluate the impact of systemic vasodilator administration in patients with sepsis and septic shock on mortality. Methods: We conducted a meta-analysis using a random effects model. Published and unpublished randomized trials in adult patients with sepsis and septic shock were included when comparing the use of systemic vasodilators against no vasodilators. The primary outcome was 28-30-day mortality, and secondary outcomes were organ function and resource use measures. Results: We included eight randomized trials (1,076 patients). In patients randomized to vasodilator arms compared with those randomized to treatment without vasodilators, the 28-30-day mortality risk ratio was 0.74 (95% confidence interval, 0.54-1.01). In a chronological cumulative meta-analysis, the association between vasodilators and survival improved over time. In a prespecified subgroup analysis in 104 patients in two randomized trials, prostacyclin analogues were associated with a decreased rate of 28-30-day mortality among patients with sepsis and septic shock (risk ratio, 0.46; 95% confidence interval, 0.25-0.85). Conclusions: In patients with sepsis and septic shock, administration of vasodilators is not associated with decreased 28-30-day mortality, but the confidence interval suggests potential benefit, and the meta-analysis might lack power. Prostacyclin appears the most promising. The results of this meta-analysis should encourage randomized trials evaluating the impact of vasodilators on mortality in sepsis.
Antibias training is increasingly identified as a strategy to reduce maternal health disparities. Evidence to guide this work is limited. We conducted a community-guided scoping review to characterize new antibias research. Four of 508 projects met our criteria: US-based, publicly funded, initiated from January 1, 2018 to June 30, 2022, and featuring an intervention to reduce bias or racism in maternal health care providers. Training was embedded in multicomponent interventions in 3 projects, limiting its evaluation as a stand-alone intervention. Major public funders have sponsored a few projects to advance antibias training research in maternal health. More support is needed to develop a rigorous and scalable evidence base.
Objective: To conduct a scoping review of literature on financial implications of surgical resident well-being. Background: Surgeon well-being affects clinical outcomes, patient experience, and health care economics. However, our understanding of the relationship between surgical resident well-being and organizational finances is limited. Methods: Authors searched PubMed, Web of Science, and Embase with no date or language restrictions. Searches of the gray literature included hand references of articles selected for data extraction and reviewing conference abstracts from Embase. Two reviewers screened articles for eligibility based on title and abstract then reviewed eligible articles in their entirety. Data were extracted and analyzed using conventional content analysis. Results: Twenty-five articles were included, 5 (20%) published between 2003 and 2010, 12 (48%) between 2011 and 2018, and 8 (32%) between 2019 and 2021. One (4%) had an aim directly related to the research question, but financial implications were not considered from the institutional perspective. All others explored factors impacting well-being or workplace sequelae of well-being, but the economics of these elements were not the primary focus. Analysis of content surrounding financial considerations of resident well-being revealed 5 categories; however, no articles provided a comprehensive business case for investing in resident well-being from the institutional perspective. Conclusions: Although the number of publications identified through the present scoping review is relatively small, the emergence of publications referencing economic issues associated with surgical resident well-being may suggest a growing recognition of this area’s importance. This scoping review highlights a gap in the literature, which should be addressed to drive the system-level change needed to improve surgical resident well-being.
Abstract Purpose To assess the impact of primary‐site surgery plus systemic therapy compared to systemic therapy alone on overall survival in common metastatic cancer types. Methods Data sources included Embase, PubMed, and Web of Science (January 1, 1995–March 22, 2023). Randomized controlled trials were included that enrolled patients diagnosed with the 10 most common de novo metastatic cancer types in the Surveillance, Epidemiology, and End Results database and randomized patients to resection of the primary site and systemic therapy versus systemic treatment alone. Random‐effects models were used to pool associations by cancer type. Results Eight studies with 1774 patients evaluating the efficacy of surgery in breast, renal, stomach, and colorectal cancer were included. There was no statistically significant reduction in risk of all‐cause mortality associated with surgical intervention for metastatic breast (HR = 0.94, 95% CI 0.63–1.40) or renal cancer (HR = 0.79, 95% CI 0.53–1.20), although results were heterogeneous ( I 2 = 73.7% and 80.6%, respectively). One study evaluating gastrectomy in metastatic stomach cancer found no benefit (HR = 1.09, 95% CI 0.78–1.52), while a small trial suggested that surgery and hyperthermic intraperitoneal chemotherapy might be beneficial for colorectal cancer with peritoneal metastasis (HR = 0.55, 95% CI 0.32–0.95). Conclusions Few randomized trials have evaluated cancer‐directed surgery among patients with metastatic solid malignancies.
Abstract Objective Accurately measuring the cost of a clinical process is critical to identifying ways to increase the value of a healthcare process. The objective of this study was to review time‐driven activity‐based costing (TDABC) in otolaryngology and to illustrate areas where value may be increased. Data Sources PubMed, Web of Science, Embase, CINAHL Complete, and Business Source Complete from database inception to August 2024. Review Methods In accordance with Preferred Reporting Items for Systematic Reviews and Meta‐analyses extension for Scoping Reviews guidelines, peer‐reviewed full‐length articles analyzing an otolaryngology care process with TDABC were included. Data collected included study characteristics, objectives, method of process mapping and costing, key study findings, subspecialty focus, and limitations. Results Nine were included in the final review. Subspecialties consisted of pediatric otolaryngology (N = 4), head and neck surgery (N = 3), and rhinology (N = 2). The primary study aims were to reduce waste (N = 4), quantify cost (N = 4), evaluate the impact of a new intervention (N = 3), and identify quality improvement opportunities (N = 3). Most articles used input from involved personnel and/or direct observation to create process maps and reviewed institutional and/or public records to obtain cost information. TDABC was primarily used to study outpatient clinics or surgeries. Common limitations included limited generalizability, susceptibility to biases, and incomplete information. Conclusion This scoping review demonstrated that TDABC can be a powerful and versatile tool for costing and identifying opportunities to increase the value of a care process in otolaryngology. Future costing studies can use TDABC to analyze care pathways in understudied otolaryngology subspecialties.
Reduced exercise capacity is commonly reported among individuals with Long COVID (LC). Cardiopulmonary exercise testing (CPET) is the gold-standard to measure exercise capacity to identify causes of exertional intolerance.
