Critical care : the official journal of the Critical Care Forum
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Editorial Comment
Rigorous scoping review of randomized trials in pediatric critical care highlights need for a rigorous rethink.
The randomized controlled trial (RCT) remains the highest-ranked study design when grading recommendations for clinical practice. In the previous issue of Critical Care, Duffett and colleagues published a scoping review of RCTs in pediatric critical care medicine and identified some serious gaps in the body of research underlying the field. Relatively few published RCTs were identified, and they were mostly small and potentially susceptible to bias. ⋯ First, one must assess current clinical practice and disease prevalence, refine definitions and measurements, and pilot-test the intervention to be studied. The first step, however, is to rigorously assess what has already been done. This step will be facilitated by the now available, innovative, online, searchable repository of RCTs in pediatric critical care on the Evidence in Pediatric Critical Care website.
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Editorial Comment
The obesity paradox and acute kidney injury: beneficial effects of hyper-inflammation?
In the general population, obesity is associated with an increased mortality risk, whereas several epidemiological studies demonstrated a protective effect of obesity in critically ill patients. In this context, Sleeman and colleagues investigated the effects of obesity on kidney function in a well-established porcine model of cardiopulmonary bypass. The authors confirm literature data that obesity per se is associated with a chronic hyper-inflammatory status. ⋯ The authors suggest that the chronic inflammation causes pre-conditioning against excessive acute hyper-inflammation. The authors have to be commended for using a long-term, clinically relevant model that, moreover, addresses a variety of putative mechanisms. The study is discussed in the context of the controversial findings that, in contrast to the existing literature on improved survival, most studies available suggest a higher incidence and severity of acute kidney injury in obese patients when compared with lean controls.