Background: The optimal protein dose in critical illness is unknown. We aim to conduct a systematic review of randomized controlled trials (RCTs) to compare the effect of higher versus lower protein delivery (with similar energy delivery between groups) on clinical and patient-centered outcomes in critically ill patients. Methods: We searched MEDLINE, EMBASE, CENTRAL and CINAHL from database inception through April 1, 2021.We included RCTs of (1) adult (age ≥ 18) critically ill patients that (2) compared higher vs lower protein with (3) similar energy intake between groups, and (4) reported clinical and/or patient-centered outcomes. We excluded studies on immunonutrition. Two authors screened and conducted quality assessment independently and in duplicate. Random-effect meta-analyses were conducted to estimate the pooled risk ratio (dichotomized outcomes) or mean difference (continuous outcomes). Results: Nineteen RCTs were included (n = 1731). Sixteen studies used primarily the enteral route to deliver protein. Intervention was started within 72 h of ICU admission in sixteen studies. The intervention lasted between 3 and 28 days. In 11 studies that reported weight-based nutrition delivery, the pooled mean protein and energy received in higher and lower protein groups were 1.31 ± 0.48 vs 0.90 ± 0.30 g/kg and 19.9 ± 6.9 versus 20.1 ± 7.1 kcal/kg, respectively. Higher vs lower protein did not significantly affect overall mortality [risk ratio 0.91, 95% confidence interval (CI) 0.75–1.10, p = 0.34] or other clinical or patient-centered outcomes. In 5 small studies, higher protein significantly attenuated muscle loss (MD −3.44% per week, 95% CI −4.99 to −1.90; p < 0.0001). Conclusion: In critically ill patients, a higher daily protein delivery was not associated with any improvement in clinical or patient-centered outcomes. Larger, and more definitive RCTs are needed to confirm the effect of muscle loss attenuation associated with higher protein delivery. PROSPERO registration number: CRD42021237530

Introduction: Despite proven effectiveness for people with chronic respiratory diseases, practical barriers to attending centre-based pulmonary rehabilitation (centre-PR) limit accessibility. We aimed to review the clinical effectiveness, components and completion rates of home-based pulmonary rehabilitation (home-PR) compared to centre-PR or usual care.Methods and analysis: Using Cochrane methodology, we searched (January 1990 to August 2021) six electronic databases using a PICOS (population, intervention, comparison, outcome, study type) search strategy, assessed Cochrane risk of bias, performed meta-analysis and narrative synthesis to answer our objectives and used the Grading of Recommendations, Assessment, Development and Evaluations framework to rate certainty of evidence.Results: We identified 16 studies (1800 COPD patients; 11 countries). The effects of home-PR on exercise capacity and/or health-related quality of life (HRQoL) were compared to either centre-PR (n=7) or usual care (n=8); one study used both comparators. Compared to usual care, home-PR significantly improved exercise capacity (standardised mean difference (SMD) 0.88, 95% CI 0.32–1.44; p=0.002) and HRQoL (SMD −0.62, 95% CI −0.88–−0.36; p<0.001). Compared to centre-PR, home-PR showed no significant difference in exercise capacity (SMD −0.10, 95% CI −0.25–0.05; p=0.21) or HRQoL (SMD 0.01, 95% CI −0.15–0.17; p=0.87).Conclusion: Home-PR is as effective as centre-PR in improving functional exercise capacity and quality of life compared to usual care, and is an option to enable access to pulmonary rehabilitation.

Involving patients in decision-making is an important part of patient-centred care. Research has found a discrepancy between patients’ desire to be involved and their actual involvement in healthcare decision-making. In Asia, there is a dearth of research in decision-making. Using Malaysia as an exemplar, this study aims to review the current research evidence, practices, policies, and laws with respect to patient engagement in shared decision-making (SDM) in Asia.

Cross-sectional survey. To investigate factors related to length of time between spinal cord injury (SCI) onset and start of first post-injury employment. Persons living with SCI in the community who are members of a disability support organization. Participants were randomly selected from the membership list of a non-governmental voluntary organization. They met the following four criteria: traumatic SCI, minimum of 15 years of age at the time of survey, a minimum of 2 years after SCI and had been employed for some time since SCI. The main outcome measure was time (in years) from injury onset to beginning first post-injury job. Participants averaged 4.9 years (s.d. 5.1) from the time of SCI to their first post-injury job, with a range of 3 months to 20 years. Fifty percent of the participants who eventually returned to work had done so by 4 years. Return to pre-injury employer and employment were associated with early return, whereas having less years in education and being older at the time of injury were associated with longer time to return to work. Rehabilitation team need to consider return to employment as a realistic goal even many years after SCI. Perhaps a focus on returning more people to their pre-injury employer and employment with added focus and input from rehabilitation team for those with lower education status and older age at time of injury might expedite the process of reintegration.

This study aims to determine the most efficacious dose of Botulinum neurotoxin type A (BoNT-A) in reducing sialorrhea in Asian adults with neurological diseases. A prospective, double-blind randomized controlled trial was conducted over 24 weeks. Thirty patients with significant sialorrhea were randomly assigned to receive a BoNT-A (Dysport^®) injection into the submandibular and the parotid glands bilaterally via an ultrasound guidance. The total dose given per patient was either BoNT-A injection of (i) 50 U; (ii) 100 U; or (iii) 200 U. The primary outcome was the amount of saliva reduction, measured by the differential weight (wet versus dry) of intraoral dental gauze at baseline and at 2, 6, 12, and 24 weeks after injection. The secondary outcome was the subjective report of drooling using the Drooling Frequency and Severity Scale (DFS). Saliva reduction was observed in response to all BoNT-A doses in 17 patients who completed the assessments. Although no statistically significant difference among the doses was found, the measured reduction was greater in groups that received higher doses (100 U and 200 U). The group receiving 200 U of Dysport^® showed the greatest reduction of saliva until 24 weeks and reported the most significant improvement in the DFS score.