BackgroundShared decision-making (SDM) is rarely implemented in pediatric practice. Pediatric health decision-making differs from that of adult practice. Yet, little is known about the factors that influence the implementation of pediatric shared decision-making (SDM). We synthesized pediatric SDM barriers and facilitators from the perspectives of healthcare providers (HCP), parents, children, and observers (i.e., persons who evaluated the SDM process, but were not directly involved).MethodsWe conducted a systematic review guided by the Ottawa Model of Research Use (OMRU). We searched MEDLINE, EMBASE, Cochrane Library, CINAHL, PubMed, and PsycINFO (inception to March 2017) and included studies that reported clinical pediatric SDM barriers and/or facilitators from the perspective of HCPs, parents, children, and/or observers. We considered all or no comparison groups and included all study designs reporting original data. Content analysis was used to synthesize barriers and facilitators and categorized them according to the OMRU levels (i.e., decision, innovation, adopters, relational, and environment) and participant types (i.e., HCP, parents, children, and observers). We used the Mixed Methods Appraisal Tool to appraise study quality.ResultsOf 20,008 identified citations, 79 were included. At each OMRU level, the most frequent barriers were features of the options (decision), poor quality information (innovation), parent/child emotional state (adopter), power relations (relational), and insufficient time (environment). The most frequent facilitators were low stake decisions (decision), good quality information (innovation), agreement with SDM (adopter), trust and respect (relational), and SDM tools/resources (environment). Across participant types, the most frequent barriers were insufficient time (HCPs), features of the options (parents), power imbalances (children), and HCP skill for SDM (observers). The most frequent facilitators were good quality information (HCP) and agreement with SDM (parents and children). There was no consistent facilitator category for observers. Overall, study quality was moderate with quantitative studies having the highest ratings and mixed-method studies having the lowest ratings.ConclusionsNumerous diverse and interrelated factors influence SDM use in pediatric clinical practice. Our findings can be used to identify potential pediatric SDM barriers and facilitators, guide context-specific barrier and facilitator assessments, and inform interventions for implementing SDM in pediatric practice.Trial RegistrationPROSPERO CRD42015020527Electronic supplementary materialThe online version of this article (10.1186/s13012-018-0851-5) contains supplementary material, which is available to authorized users.

BACKGROUND The risks and benefits of red blood cell (RBC) transfusion in palliative care patients remain poorly understood. We reviewed the literature to summarize available information on RBC transfusion in this population. STUDY DESIGN AND METHODS We searched electronic databases (MEDLINE, Embase, PsycINFO, CINAHL) from inception through September 2016 to identify studies reporting data on palliative patients receiving RBC transfusion. Original studies that assessed RBC transfusion as an intervention and reported at least one clinical outcome were included. Study characteristics, results on transfusion‐related outcomes, and authors' conclusions on the value of transfusion in palliative patients were abstracted and reported. RESULTS We identified 1839 studies, of which 137 were selected for data extraction and 13 were included (11 case series, one prospective cohort, and one retrospective cohort). Nine studies addressed symptom relief following transfusion using subjective symptom scales, of which eight (89%) indicated some degree of short‐term benefit and one study (11%) showed no benefit. Posttransfusion survival was reported in four studies—one demonstrated prolonged survival in patients receiving RBC transfusion; three had no comparison group. Other outcomes reported included hemoglobin values posttransfusion in four studies and adverse events following transfusion in three studies. CONCLUSIONS In palliative care, RBC transfusion may provide symptom relief and improve subjective well‐being, though the duration and magnitude of this effect, and transfusion‐associated risks specific to this population remain unclear. Currently, no high quality evidence exists to support or guide the use of RBC transfusion in this population. Moreover, the clinical heterogeneity within the palliative population limits the interpretation of most studies.

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Background Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) are widely used in clinical practice. The safety and efficacy of these agents in peritoneal dialysis (PD) patients are unclear. Objectives We conducted a systematic review to study the safety and efficacy of ACEI and ARB use in PD patients. Primary outcome measures were mortality and cardiovascular (CV) events; secondary outcome measures were renal function, proteinuria, hyperkalemia, and erythropoietin requirement at 3 months. Methods We searched Medline, EMBASE, Cochrane Central Register of Controlled Trials, trial registry Web sites, reference lists of eligible and review articles, as well as abstracts from the American Society of Nephrology and Canadian Society of Nephrology meetings. To be eligible, studies had to be randomized controlled trials that allocated PD patients to ACEI and ARB use or to placebo or other antihypertensive medications, included adult patients, and reported on at least one of the outcome measures. Results 418 citations were identified. Four met the eligibility criteria. Three examined CV events and mortality, of which two studies did not have any events. The third showed no statistically significant difference between control and treatment groups in either CV events or mortality: odds ratio 1.56 [95% confidence interval (CI) 0.24 – 10.05] for mortality and odds ratio 1.00 (95% CI 0.19 – 5.40) for CV events. Two studies reported renal function at 12 months and the weighted mean difference was 0.91 mL/minute/1.73 m2 (95% CI 0.14 – 1.68), favoring ACEI and ARB use. Conclusions In PD patients, evidence for the use of ACEIs and ARBs for reduction of mortality and CV events is lacking. Limited data suggest that they slow the loss of residual renal function.