Aerosol generating procedures (AGPs) may expose health care workers (HCWs) to pathogens causing acute respiratory infections (ARIs), but the risk of transmission of ARIs from AGPs is not fully known. We sought to determine the clinical evidence for the risk of transmission of ARIs to HCWs caring for patients undergoing AGPs compared with the risk of transmission to HCWs caring for patients not undergoing AGPs. We searched PubMed, EMBASE, MEDLINE, CINAHL, the Cochrane Library, University of York CRD databases, EuroScan, LILACS, Indian Medlars, Index Medicus for SE Asia, international health technology agencies and the Internet in all languages for articles from 01/01/1990 to 22/10/2010. Independent reviewers screened abstracts using pre-defined criteria, obtained full-text articles, selected relevant studies, and abstracted data. Disagreements were resolved by consensus. The outcome of interest was risk of ARI transmission. The quality of evidence was rated using the GRADE system. We identified 5 case-control and 5 retrospective cohort studies which evaluated transmission of SARS to HCWs. Procedures reported to present an increased risk of transmission included [n; pooled OR(95%CI)] tracheal intubation [n = 4 cohort; 6.6 (2.3, 18.9), and n = 4 case-control; 6.6 (4.1, 10.6)], non-invasive ventilation [n = 2 cohort; OR 3.1(1.4, 6.8)], tracheotomy [n = 1 case-control; 4.2 (1.5, 11.5)] and manual ventilation before intubation [n = 1 cohort; OR 2.8 (1.3, 6.4)]. Other intubation associated procedures, endotracheal aspiration, suction of body fluids, bronchoscopy, nebulizer treatment, administration of O2, high flow O2, manipulation of O2 mask or BiPAP mask, defibrillation, chest compressions, insertion of nasogastric tube, and collection of sputum were not significant. Our findings suggest that some procedures potentially capable of generating aerosols have been associated with increased risk of SARS transmission to HCWs or were a risk factor for transmission, with the most consistent association across multiple studies identified with tracheal intubation.

DiscussionNewborn infants of diabetic mothers are at risk of developing severe hypoglycaemia. Good control of maternal diabetes during pregnancy increases the fetal survival rate.3 Recent reports4 support the hypothesis that neonatal hypoglycaemia is due to islet-cell hyperplasia, which in turn may be caused in utero by maternal hyperglycaemia. Since perfect control of maternal blood glucose is aimed at during pregnancy, it is logical to avoid excessive stimulation of fetal insulin secretion immediately before delivery.5The combined infusion of insulin and glucose is a simple way of controlling the maternal blood glucose concentration during labour. It also permits adequate hydration of the mother and prevents starvation ketosis. At the same time the stomach may be kept empty, so that a general anaesthetic can be given without delay.Infused insulin is cleared extremely rapidly from the plasma, and by means of an insulin infusion the maternal plasma insulin concentration may be readily adjusted to achieve more-constant blood glucose concentrations. Immediately after delivery maternal insulin requirements fall, and the infusion rate of insulin may be lowered accordingly.Measurement of blood glucose with Dextrostix and the reflectance meter is simple and may be performed by nurses on capillary blood samples obtained by finger-prick at the bedside. The result is available within two minutes and compares favourably with estimations performed by a standard laboratory method. Repeated estimations may be performed without undue discomfort to the patient. (During one premature labour over 100 capillary blood samples were taken in 48 hours.)Provided that simple rules are observed and equipment is properly standardised, management of diabetes during labour with this method becomes a simple procedure suitable for all obstetric units.We thank Mr M Cameron for the obstetric care of these patients, and the labour ward staff and Sister Susan Judd and the house physicians of the medical unit for help with management of the infusions.

Background: There is an increasing demand to incorporate patient-reported outcome measures (PROMs) such as quality of life (QOL) in decision-making when selecting a chronic dialysis modality. Objective: To compare the change in QOL over time among similar patients on different dialysis modalities to provide unique and novel insights on the impact of dialysis modality on PROMs. Design: Systematic reviews, randomized controlled trials, and nonrandomized controlled trials were examined via a comprehensive search strategy incorporating multiple bibliographic databases. Setting: Data were extracted from relevant studies from January 1, 2000 to December 31, 2019 without limitations on country of study conduction. Patients: Eligible studies included adults (≥18 years) with end-stage kidney disease of any cause who were prescribed dialysis treatment (either as lifetime treatment or bridge to transplant). Measurements: The 5 comparisons were peritoneal dialysis (PD) vs in-center hemodialysis (ICHD), home hemodialysis (HHD) vs ICHD, HHD modalities compared with one another, HHD vs PD, and self-care ICHD vs traditional nurse-based ICHD. Methods: Included studies compared adults on different dialysis modalities with repeat measures within individuals to determine changes in QOL between dialysis modalities (in-center or home dialysis). Methodological quality was assessed by the Scottish Intercollegiate Guidelines Network (SIGN 50) checklist. A narrative synthesis was conducted, synthesizing the direction and size of any observed effects across studies. Results: Two randomized controlled trials and 9 prospective cohort studies involving a combined total of 3711 participants were included. Comparing PD and ICHD, 5 out of 9 studies found significant differences ( P < .05) favoring PD in the change of multiple QOL domains, including “physical component score,” “role of social component score,” “cognitive status,” “role limitation due to emotional function,” “role limitation due to physical function,” “bodily pain,” “burden of kidney disease,” “effects of kidney disease on daily life,” “symptoms/problems,” “sexual function,” “finance,” and “patient satisfaction.” Conversely, 3 of these studies demonstrated statistically significant differences ( P < .05) favoring ICHD in the domains of “role limitation due to physical function,” “general health,” “support from staff,” “sleep quality,” “social support,” “health status,” “social interaction,” “body image,” and “overall health.” Comparing HHD and ICHD, significant differences ( P < .05) favoring HHD for the QOL domains of “general health,” “burden of kidney disease,” and the visual analogue scale were reported. Limitations: Our study is constrained by the small sample sizes of included studies, as well as heterogeneity among both study populations and validated QOL scales, limiting inter-study comparison. Conclusions: We identified differences in specific QOL domains between dialysis modalities that may aid in patient decision-making based on individual priorities. Trial registration: PROSPERO Registration Number: CRD42016046980. Primary funding source: The original research for this study was derived from the Canadian Agency for Drugs and Technologies in Health (CADTH) 2017 optimal use report, titled “Dialysis Modalities for the Treatment of End-Stage Kidney Disease: A Health Technology Assessment.” The CADTH receives funding from Canada’s federal, provincial, and territorial governments, with the exception of Quebec.

No abstract

For treating active tuberculosis (TB), some 4-month treatment regimens may be as effective and safe as the standard 6-month treatment regimen. However, there are also 4-month treatment regimens that seem to be less effective than the 6-month treatment regimen for treating active TB. The effectiveness of these shortened treatment regimens depends on the combination of drugs and the dose schedule. For treating active TB, a 3-month treatment regimen appears to be less effective than the standard 6-month regimen, as it is associated with a higher rate of TB recurring within 2 years after completing treatment.

The evidence regarding the cost-effectiveness of the Xpert Mycobacterium tuberculosis complex and resistance to rifampicin (Xpert MTB/RIF) test compared with smear microscopy in diagnosing tuberculosis is summarized in this report. Results from the included 6 studies showed that Xpert MTB/RIF testing is a cost-effective option compared with sputum smear microscopy. However, the generalizability of the results to the Canadian setting are unclear because of the clinical data source populations, willingness-to-pay thresholds, and assumptions used in the analyses. There is a lack of evidence regarding the cost-effectiveness of Xpert MTB/RIF testing compared with mycobacterial cultures or culture-based susceptibility testing.

It is not known if screening for latent tuberculosis infection (LTBI) is useful for reducing the risk of tuberculosis reactivation among people at risk (no evidence was found). In people with LTBI, providing treatment for the latent infection may be helpful for preventing the development of active tuberculosis disease. (In addition, LTBI treatments do not appear to increase the risk for hepatotoxicity.) Treatment effectiveness may depend on the specific LTBI treatment regimen used. For people at an increased risk for tuberculosis ― including those from areas with high rates of tuberculosis ― guidelines recommend screening and treatment for LTBI, as this may help prevent TB reactivation. Treatment is recommended for those who are 65 years old or younger and with a positive LTBI result (recommendation from 1 high-quality guideline).

There is growing awareness of the impact health technologies can have on the environment and the negative consequences of these environmental impacts on human health. However, health system decision-makers may lack the expertise, data, or resources to incorporate environmental considerations when making decisions about the adoption and use of health technologies. In this article, we describe how health technology assessment (HTA) is evolving to address climate change by providing health system decision-makers with the information they can use to reduce the impact of health care systems on the environment. Our objective is to consider approaches for including the environment domain when conducting an HTA—in particular, the use of the deliberative process—and for determining when the domain should be included. We explore the challenges of gathering the relevant data necessary to assess the environmental impact of a health technology, and we describe a “triage” approach for determining when an in-depth environmental impact assessment is warranted. We also summarize related initiatives from HTA agencies around the world.