Articles: cross-over-studies.
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Critical care medicine · Sep 2014
Gravity Predominates Over Ventilatory Pattern in the Prevention of Ventilator-Associated Pneumonia.
In the semirecumbent position, gravity-dependent dissemination of pathogens has been implicated in the pathogenesis of ventilator-associated pneumonia. We compared the preventive effects of a ventilatory strategy, aimed at decreasing pulmonary aspiration and enhancing mucus clearance versus the Trendelenburg position. ⋯ The Trendelenburg position predominates over expiratory flow bias and positive end-expiratory pressure in the prevention of gravity-dependent translocation of oropharyngeal pathogens and development of ventilator-associated pneumonia. These findings further substantiate the primary role of gravity in the pathogenesis of ventilator-associated pneumonia.
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The cluster randomized crossover (CRXO) design is gaining popularity in trial settings where individual randomization or parallel group cluster randomization is not feasible or practical. In a CRXO trial, not only are clusters of individuals rather than individuals themselves randomized to trial arms, but also each cluster participates in each arm of the trial at least once in separate periods of time.We will review publications of clinical trials undertaken in humans that have used the CRXO design. The aim of this systematic review is to summarize, as reported: the motivations for using the CRXO design, the values of the CRXO design parameters, the justification and methodology for the sample size calculations and analyses, and the quality of reporting the CRXO design aspects. ⋯ This systematic review will inform both researchers addressing CRXO methodology and trialists considering implementing the design. The results will allow focused methodological research of the CRXO design, provide practical examples for researchers of how CRXO trials have been conducted, including any shortcomings, and highlight areas where reporting and conduct may be improved.
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With implementation of the Patient Protection and Affordable Care Act, 30 million individuals are predicted to gain access to health insurance. The experience in Massachusetts, which implemented a similar reform beginning in 2006, should provide important lessons about the effect of health care reform on emergency department (ED) utilization. Our objective is to understand the extent to which Massachusetts health care reform was associated with changes in ED utilization. ⋯ The implementation of health care reform in Massachusetts was associated with a small but consistent increase in the use of the ED across the state. Whether this was due to the elimination of financial barriers to seeking care in the ED, a persistent shortage in access to primary care for those with insurance, or some other cause is not entirely clear and will need to be addressed in future research.
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Randomized Controlled Trial
Effect of cricoid pressure on placement of the I-gel(™) : a randomised study.
We studied 40 adult patients to see if cricoid pressure affected placement of the I-gel(™). In a randomised crossover design, the i-gel was placed with and without cricoid pressure, and we compared the success rate of adequate ventilation through the i-gel, time to placement and the rate of optimal position of the device between the two circumstances. ⋯ The time to achieve adequate ventilation was significantly longer (p < 0.001) with cricoid pressure than without (median difference 8 s; 95% CI for median difference 3-12 s). Cricoid pressure significantly decreases the success rate of ventilation through the i-gel, but the success rate of ventilation through the i-gel is reasonably high.