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PubMed2001

Implications of the AHRQ evidence report on acute otitis media.

OBJECTIVE: To familiarize otolaryngologists with the Agency for Healthcare Research and Quality (AHRQ) Evidence Report on Acute Otitis Media (AOM) that reviews the natural history and role of antibiotics in management. The report, by the Southern California Evidence-Based Practice Center (SC-EPC), is the most recent of 15 literature syntheses published by the AHRQ. DATA SOURCES: MEDLINE (1966 to present), Cochrane Library, EMBASE, BIOSIS, HealthSTAR, and other computerized databases; manual reference search of proceedings, articles, reports, and guidelines. STUDY SELECTION: Randomized trials and cohort studies relevant to the natural history of AOM and the efficacy of antimicrobial therapy. AOM was defined by the 11-member technical expert panel (including 2 authors, RMR and MLC) as middle-ear effusion with the rapid onset of signs or symptoms of middle ear inflammation. DATA EXTRACTION: Two physician reviewers at the Southern California Evidence-Based Practice Center independently rated the articles and extracted data. DATA SYNTHESIS: Children receiving placebo or no antimicrobial had a pooled clinical success rate of 81% at 1 to 7 days (95% CI, 72% to 90%), with no increase in suppurative complications when followed closely. Amoxicillin or ampicillin increased the absolute success rate by 12.3% (95% CI, 2.8% to 21.8%) in 5 studies pooled using random effects meta-analysis. The antimicrobial benefit was robust to sensitivity analysis. In contrast, success rates were not influenced by the choice or duration of therapy. CONCLUSIONS: The AHRQ report emphasizes middle-ear effusion as a preeminent criteria for AOM diagnosis and provides extensive evidence tables on natural history and antimicrobial impact. About 8 children must receive antibiotics to avoid 1 clinical failure, but children younger than age 2 years or with severe symptoms may benefit more. The report is a starting point for organizations seeking to develop AOM guidelines, performance measures, and other quality improvement tools.

Acute Disease↗
PubMed2001

Lingual flap retraction and prevention of lingual nerve damage associated with third molar surgery: a systematic review of the literature.

OBJECTIVE: Lingual nerve damage sometimes occurs after the removal of third molars. The use of a lingual retractor has been advocated to protect the lingual nerve. A systematic review of the literature was undertaken to evaluate the incidence of lingual nerve damage after third molar surgery and the effect of a lingual retractor on nerve damage. STUDY DESIGN: An exhaustive computerized search of several databases and references cited in the various studies was performed. Predetermined inclusion and exclusion criteria were used to identify the 8 published studies acceptable for detailed analysis. The incidence and spontaneous recovery of lingual nerve injury for the following 3 surgical techniques were evaluated: the buccal approach with lingual flap retraction (BA+), or the buccal approach without lingual flap retraction (BA-), and the lingual split technique with lingual flap retraction (LS). RESULTS: In the 8 selected articles, lingual nerve injury occurred in 9.6%, 6.4%, and 0.6% of the pooled LS, BA+, and BA- procedures, respectively. On the basis of risk ratios comparing combined incidence rates, lingual nerve injury is 8.8 times more likely to occur in BA+ than in BA- procedures (CI = 4.3-17.8), 13.3 times more likely to occur in LS than in BA- procedures (CI = 6.6-26.9), and 1.5 times more likely to occur in LS than in BA+ procedures (CI = 1.2-1.8). Permanent lingual nerve injury occurred in 0.1%, 0.6%, and 0.2% of the combined LS, BA+, and BA- procedures, respectively. The combined permanent incidence risk ratios were not calculated because of the low permanent incidence rates. CONCLUSIONS: The use of a lingual nerve retractor during third molar surgery was associated with an increased incidence of temporary nerve damage and was neither protective nor detrimental with respect to the incidence of permanent nerve damage.

Cranial Nerve Injuries↗
PubMed1999

Ecosystem rooting depth determined with caves and DNA.

Belowground vertical community composition and maximum rooting depth of the Edwards Plateau of central Texas were determined by using DNA sequence variation to identify roots from caves 5-65 m deep. Roots from caves were identified by comparing their DNA sequences for the internal transcribed spacer (ITS) region of the 18S-26S ribosomal DNA repeat against a reference ITS database developed for woody plants of the region. Sequencing the ITS provides, to our knowledge, the first universal method for identifying plant roots. At least six tree species in the system grew roots deeper than 5 m, but only the evergreen oak, Quercus fusiformis, was found below 10 m. The maximum rooting depth for the ecosystem was approximately 25 m. (18)O isotopic signatures for stem water of Q. fusiformis confirmed water uptake from 18 m underground. The availability of resources at depth, coupled with small surface pools of water and nutrients, may explain the occurrence of deep roots in this and other systems.

Base Sequence↗
PubMed2006

High dynamic range characterization of the trauma patient plasma proteome.

Although human plasma represents an attractive sample for disease biomarker discovery, the extreme complexity and large dynamic range in protein concentrations present significant challenges for characterization, candidate biomarker discovery, and validation. Herein we describe a strategy that combines immunoaffinity subtraction and subsequent chemical fractionation based on cysteinyl peptide and N-glycopeptide captures with two-dimensional LC-MS/MS to increase the dynamic range of analysis for plasma. Application of this "divide-and-conquer" strategy to trauma patient plasma significantly improved the overall dynamic range of detection and resulted in confident identification of 22,267 unique peptides from four different peptide populations (cysteinyl peptides, non-cysteinyl peptides, N-glycopeptides, and non-glycopeptides) that covered 3,654 different proteins with 1,494 proteins identified by multiple peptides. Numerous low abundance proteins were identified, exemplified by 78 "classic" cytokines and cytokine receptors and by 136 human cell differentiation molecules. Additionally a total of 2,910 different N-glycopeptides that correspond to 662 N-glycoproteins and 1,553 N-glycosylation sites were identified. A panel of the proteins identified in this study is known to be involved in inflammation and immune responses. This study established an extensive reference protein database for trauma patients that provides a foundation for future high throughput quantitative plasma proteomic studies designed to elucidate the mechanisms that underlie systemic inflammatory responses.

Blood Proteins↗
PubMed2003

Dietary factors in the prevention of dental caries: a systematic review.

The aim of this study was, systematically, to evaluate the effect of dietary changes in the prevention of dental caries. A search and analysis strategy was followed, as suggested by the Swedish Council on Technology Assessment in Health Care (SBU). The search strategy for articles published in 1966-2003 was performed using electronic databases and reference lists of articles and selected textbooks. Out of 714 articles originally identified, 18 met the inclusion criteria for a randomized or controlled clinical trial--at least 2 years' follow-up and caries increment as a primary endpoint. This included the total or partial substitution of sucrose with sugar substitutes or the addition of protective foods to chewing gum. No study was found evaluating the effect of information designed to reduce sugar intake/frequency as a single preventive measure. It is suggested that the evidence for the use of sorbitol or xylitol in chewing gum, or for the use of invert sugar, is inconclusive. No caries-preventive effect was found from adding calcium phosphate or dicalcium phosphate dihydrate to chewing gums. The review dearly demonstrates the need for well-designed randomized clinical studies with adequate control groups and high compliance.

Calcium Phosphates↗
PubMed2004

Assessing professionalism: a review of the literature.

Although assessing professionalism poses many challenges, gauging and detecting changes in professionalism is impossible without measurement. This paper is a review of techniques used to assess professionalism during the past 20 years. The authors searched five electronic databases and reference lists from 1982 to 2002. Eighty-eight assessments were retained and organized into content area addressed (i.e. ethics, personal characteristics, comprehensive professionalism, diversity) and type of outcome examined (i.e. affective, cognitive, behavioral, environmental). Instead of creating new professionalism assessments, existing assessments should be improved. Also, more studies on the predictive validity of assessments and their use as part of formative evaluation systems are recommended. Based on the review, suggestions are presented for assessing medical students, resident physicians and practicing physicians.

Educational Measurement↗
PubMed2001

Implementing evidence in Finnish primary care. Use of electronic guidelines in daily practice.

In Finland, electronic guidelines have provided general practitioners (GPs) with a source of up-to-date information at their fingertips since 1989. The Physician's Desk Reference and Database (PDRD) covers the majority of problems encountered in primary care with some 1,000 articles. These are available in electronic format, updated every 4 months, and as a book published in a fully revised edition every 2 years. Physicians use these guidelines as a routine part of their daily work. They seek information for both common and rare health problems and use it to plan diagnostic strategies as well as treatment and follow-up. In nearly 90% of cases the doctor finds the information she needs from the guidelines. The electronic version is user-friendly; typically the relevant article is found and read in 2 min. Patients find it reassuring when their doctor uses guidelines to select optimal treatment. Other Nordic countries are aslo producing several national guidelines, but Finland has so far the widest scope and longest experience in this area. An English version of the PDRD guidelines (Evidence-Based Medicine Guidelines) is available, and a Swedish-language version will be completed in 2002.

Decision Support Systems, Clinical↗
PubMed2006

Phytosterols/stanols lower cholesterol concentrations in familial hypercholesterolemic subjects: a systematic review with meta-analysis.

BACKGROUND: To-date, reviews regarding the cholesterol lowering capacity of phytosterols/stanols have focused on normo- and hypercholesterolemic (HC) subjects. Familial hypercholestrolemia (FH) is characterized by very high low-density lipoprotein cholesterol (LDL-C) concentrations and is considered a world public health problem due to the high incidence of premature coronary heart disease (CHD) in these patients. OBJECTIVE: To conduct a systematic review that investigates the efficacy of phytosterols/stanols in lowering total cholesterol (TC) and LDL-C concentrations in FH subjects. DESIGN: Randomized controlled intervention trials with the primary objective to investigate the effects of phytosterols/stanols on lipid concentrations in FH subjects were identified through selected international journal databases and reference lists of relevant publications. Two researchers extracted data from each identified trial and only trials of sufficient quality (e.g. controlled, randomized, double-blind, good compliance, sufficient statistical power) were included in the review. The main outcome measures were differences between treatment and control groups for LDL-C, TC, high-density lipoprotein cholesterol (HDL-C) and triacylglycerol (TG). RESULTS: Six out of 13 studies were of sufficient quality. Two were excluded from the meta-analysis because the sterols were administered in the granulate form at very high dosages (12 g/day and 24 g/day) compared to the other studies that used fat spreads as vehicle with dosages ranging from 1.6-2.8 g/day. The subjects were heterozygous, aged 2-69 years with baseline TC and LDL-C concentrations of +/-7 mmol/L and +/-5.4 mmol/L, respectively. The duration of the studies ranged from 4 weeks to 3 months. Fat spreads enriched with 2.3 +/- 0.5 g phytosterols/stanols per day significantly reduced TC from 7 to 11% with a mean decrease of 0.65 mmol/L [95% CI -0.88, -0.42 mmol/L], p < 0.00001 and LDL-C from 10-15% with a mean decrease of 0.64 mmol/L [95% CI -0.86, -0.43 mmol/L], p < 0.00001 in 6.5 +/- 1.9 weeks compared to control treatment, without any adverse effects. TG and HDL-C concentrations were not affected. CONCLUSION: Phytosterols/stanols may offer an effective adjunct to the cholesterol lowering treatment strategy of FH patients.

Adolescent↗
PubMed2005

Premature ventricular contraction classification by the Kth nearest-neighbours rule.

An analysis of electrocardiographic pattern recognition parameters for premature ventricular contraction (PVC) and normal (N) beat classification is presented. Twenty-six parameters were defined: 11 x 2 for the two electrocardiogram (ECG) leads, width of the complex and three parameters derived from a single-plane vectorcardiogram (VCG). Some of the parameters include amplitudes of maximal positive and maximal negative peaks, area of absolute values, area of positive values, area of negative values, number of samples with 70% higher amplitude than that of the highest peak, amplitude and angle of the QRS vector in a VCG plane. They were measured for all heartbeats annotated as N or PVC in all 48 ECG recordings of the MIT-BIH arrhythmia database. Two reference sets for the Kth nearest-neighbours rule were used-global and local. The classification indices obtained with the global reference set were 75.4% specificity and 80.9% sensitivity. Using the local reference set we increased the specificity to 96.7% and the sensitivity to 96.9%. The achieved specificity and sensitivity are comparable with, and greater than, the results reported in the literature.

Data Interpretation, Statistical↗
PubMed2006

Occurrence and outcome of delirium in medical in-patients: a systematic literature review.

BACKGROUND: Despite the acknowledged clinical importance of delirium, research evidence for measures to improve its management is sparse. A necessary first step to devising appropriate strategies is to understand how common it is and what its outcomes are in any particular setting. OBJECTIVE: To determine the occurrence of delirium and its outcomes in medical in-patients, through a systematic review of the literature. METHOD: We searched electronic medical databases, the Consultation-Liaison Literature Database and reference lists and bibliographies for potentially relevant studies. Studies were selected, quality assessed and data extracted according to preset protocols. RESULTS: Results for the occurrence of delirium in medical in-patients were available for 42 cohorts. Prevalence of delirium at admission ranged from 10 to 31%, incidence of new delirium per admission ranged from 3 to 29% and occurrence rate per admission varied between 11 and 42%. Results for outcomes were available for 19 study cohorts. Delirium was associated with increased mortality at discharge and at 12 months, increased length of hospital stay (LOS) and institutionalisation. A significant proportion of patients had persistent symptoms of delirium at discharge and at 6 and 12 months. CONCLUSION: Delirium is common in medical in-patients and has serious adverse effects on mortality, functional outcomes, LOS and institutionalisation. The development of appropriate strategies to improve its management should be a clinical and research priority. As delirium prevalent at hospital admission is a significant problem, research is also needed into preventative measures that could be applied in community settings.

Aged↗
PubMed2006

A systematic review on the efficacy of cytoreductive surgery combined with perioperative intraperitoneal chemotherapy for diffuse malignancy peritoneal mesothelioma.

BACKGROUND: In the past, diffuse malignant peritoneal mesothelioma (DMPM) was regarded as a preterminal condition. The length of survival was dependent upon the aggressive versus indolent biologic behavior of the neoplasm. The overall median survival was approximately 1 year after systemic chemotherapy. Cytoreductive surgery (CRS) combined with perioperative intraperitoneal chemotherapy (PIC) has been used as a treatment alternative, but the efficacy of this combined treatment remains to be established. PATIENTS AND METHODS: Searches for relevant studies published in peer-reviewed medical journals on CRS and PIC for DMPM before May 2006 were carried out on six databases. The reference lists of all retrieved articles were reviewed for further identification of potentially relevant studies. Expert academic surgeons in Washington, DC, USA were asked whether they knew about any important unpublished data. Two investigators independently evaluated each study according to predefined criteria. The quality of each study was assessed. Clinical effectiveness was synthesized through a narrative review with full tabulation of results of all included studies. RESULTS: Seven prospective observational studies from six tertiary institutions were available, allowing 240 DMPM patients for assessment. The median survival ranged from 34-92 months. The 1-, 3- and 5-year survival varied from 60% to 88%, 43% to 65% and 29% to 59%, respectively. The perioperative morbidity varied from 25% to 40% and mortality ranged from 0% to 8%. CONCLUSIONS: This systematic review evaluated the current evidence for CRS and PIC for DMPM. Seven observational studies were available for assessment, which demonstrated an improved overall survival, as compared to historical controls, using systemic chemotherapy and palliative surgery.

Antibiotics, Antineoplastic↗
PubMed2002

Multiple sequence alignment with arbitrary gap costs: computing an optimal solution using polyhedral combinatorics.

Multiple sequence alignment is one of the dominant problems in computational molecular biology. Numerous scoring functions and methods have been proposed, most of which result in NP-hard problems. In this paper we propose for the first time a general formulation for multiple alignment with arbitrary gap-costs based on an integer linear program (ILP). In addition we describe a branch-and-cut algorithm to effectively solve the ILP to optimality. We evaluate the performances of our approach in terms of running time and quality of the alignments using the BAliBase database of reference alignments. The results show that our implementation ranks amongst the best programs developed so far.

Algorithms↗
PubMed2006

Disease-specific health education for COPD: a systematic review of changes in health outcomes.

A systematic review was conducted to determine the benefits of disease-specific health education for people with chronic obstructive pulmonary disease (COPD). A search was conducted through Medline, CINAHL, PsycINFO, Embase, Cochrane Library, Physiotherapy Evidence Database and reference lists to obtain publications reporting on educational interventions compared with usual medical care. Two reviewers independently assessed each paper for methodological quality and data extraction. Thirteen publications describing 10 randomized controlled trials were identified for inclusion. The studies reported on a very broad variety of outcomes and follow-up periods, making a meta-analysis not possible for most measures. Didactical educational intervention for the COPD population appeared to have minimal effect on health outcomes including quality of life, health care utilization, exercise capacity or lung function and is therefore not the education delivery method recommended. Education focusing on self-management showed encouraging results with a tendency for improvements in quality of life and health care utilization, but the results did not reach statistical significance as sample sizes were insufficient to detect an effect. Further research is required into self-management education as it is not possible to make generalizations from the current published literature as to the benefits in changing health status in the COPD population.

Health Services↗
PubMed2004

Vasectomy techniques for male sterilization: systematic Cochrane review of randomized controlled trials and controlled clinical trials.

BACKGROUND: The review aimed to compare the effectiveness, safety and acceptability of vasectomy techniques for male sterilization. METHODS: We searched five computerized databases and reference lists of relevant articles and book chapters for randomized controlled trials (RCTs) and controlled clinical trials (CCTs) comparing vasectomy techniques. Two reviewers independently extracted data from eligible articles. RESULTS: Two poor-quality trials compared vas occlusion with clips versus a conventional technique, and four poor-quality trials examined vas irrigation with water versus no irrigation or irrigation with euflavine. No significant differences regarding the primary outcome of time to azoospermia were found. However, one trial reported fewer median number of ejaculations to azoospermia with euflavine rather than water irrigation. An interim report of a high-quality trial comparing vasectomy with and without fascial interposition found more azoospermia with fascial interposition but also more surgical difficulties. CONCLUSIONS: No conclusions can be reached regarding the effectiveness, safety and acceptability of vas occlusion techniques or vas irrigation since only low-quality, underpowered studies were available. Fascial interposition had improved vasectomy success but also increased surgical difficulty. High-quality, adequately reported RCTs are required. More work is also needed in the standardization of follow-up protocols, evaluation of vasectomy success and failure, recanalization and analytical methods.

Controlled Clinical Trials as Topic↗
PubMed2005

Congenital structural anomalies in offspring of women with epilepsy--a population-based cohort study in Finland.

BACKGROUND: Offspring of women with epilepsy may have an increased risk for congenital malformations, probably attributable to maternal antiepileptic medication. We conducted this population-based study to obtain valid and accurate estimates on major congenital malformations in the offspring of women with epilepsy, based on a large and representative patient cohort. METHODS: We identified all women (n = 6,535) entitled to full reimbursement for antiepileptic medication indicated for epilepsy for the first time between 1985 and 1994 from the Social Insurance Institution of Finland database. A reference cohort (n = 14,704) was identified from the Finnish Population Register Centre. Information on children born between 1993 and 2000 (patient cohort, n = 2,162; reference cohort, n = 5,413) was obtained from the Medical Birth Register. Information on children born with malformation (patient cohort, n = 116; reference cohort, n = 151) was obtained from the Finnish Register of Congenital Malformations. RESULTS: The prevalence of major malformation was 54/1,000 births among patients with epilepsy and 28/1,000 births among mothers without epilepsy, corresponding to a 2-fold overall risk for malformation in the offspring of women with epilepsy. The risk for spina bifida [odds ratio (OR) = 11.3, 95% confidence interval (CI) 2.34-108] and congenital anomalies of genital organs (OR = 8.38, 95% CI 2.15-47.4) was substantially elevated in the offspring of mothers with epilepsy. CONCLUSIONS: The absolute excess in the prevalence of major malformations was 26/1,000 births in the offspring of mothers with epilepsy in relation to the offspring of reference mothers. The highest relative risk was observed in spina bifida and congenital anomalies of genital organs. However, these malformations cover only a small proportion of all major malformations.

Abnormalities, Drug-Induced↗
PubMed2006

Nutritional interventions and outcome in patients with cancer or preinvasive lesions: systematic review.

BACKGROUND: Dietary modifications and supplements are used widely by patients with cancer and preinvasive lesions as an adjunct to standard treatment. Given the widespread use of nutritional modifications and supplements by such patients and concerns about the lack of benefit and possible harm, we conducted a systematic review of randomized controlled trials to examine the effect of nutritional interventions on patients with cancer or preinvasive lesions. METHODS: We searched electronic databases and reference lists to locate all eligible trials and analyzed trial quality. Outcome measures were all-cause and cancer mortality, disease-free survival, cancer recurrence, second primary cancer, recurrence of a preinvasive lesion, or progression to cancer. Results of individual trials were combined by use of random-effects meta-analyses. RESULTS: We identified 59 eligible trials, 25 in patients with cancer and 34 in patients with preinvasive lesions, respectively. Trial quality was generally low; only three trials (two of cancer and one of preinvasive lesions) had adequate methods for generating the allocation sequence, allocation concealment, and masking both outcome assessors and participants. The combined odds ratio (OR) for the effect of a healthy diet-given alone or with dietary supplements, weight loss, or exercise-on all-cause mortality was 0.90 (95% confidence interval [CI] = 0.46 to 1.77). There was no evidence of an association between the use of antioxidant (OR = 1.01, 95% CI = 0.88 to 1.15) or retinol (OR = 0.97, 95% CI = 0.83 to 1.13) supplements and all-cause mortality. Meta-analyses of all other outcomes did not show clear evidence of benefit or harm. CONCLUSIONS: The impact of most nutritional interventions cannot be reliably estimated because of the limited number of trials, many of which were of low quality. There is no evidence that dietary modification by cancer patients improves survival and benefits disease prognosis.

Antioxidants↗
PubMed1999

The visual communication of risk.

This paper 1) provides reasons why graphics should be effective aids to communicate risk; 2) reviews the use of visuals, especially graphical displays, to communicate risk; 3) discusses issues to consider when designing graphs to communicate risk; and 4) provides suggestions for future research. Key articles and materials were obtained from MEDLINE(R) and PsychInfo(R) databases, from reference article citations, and from discussion with experts in risk communication. Research has been devoted primarily to communicating risk magnitudes. Among the various graphical displays, the risk ladder appears to be a promising tool for communicating absolute and relative risks. Preliminary evidence suggests that people understand risk information presented in histograms and pie charts. Areas that need further attention include 1) applying theoretical models to the visual communication of risk, 2) testing which graphical displays can be applied best to different risk communication tasks (e.g., which graphs best convey absolute or relative risks), 3) communicating risk uncertainty, and 4) testing whether the lay public's perceptions and understanding of risk varies by graphical format and whether the addition of graphical displays improves comprehension substantially beyond numerical or narrative translations of risk and, if so, by how much. There is a need to ascertain the extent to which graphics and other visuals enhance the public's understanding of disease risk to facilitate decision-making and behavioral change processes. Nine suggestions are provided to help achieve these ends.

Audiovisual Aids↗
PubMed2007

Acupuncture treatment for chronic knee pain: a systematic review.

OBJECTIVES: To evaluate the effects of acupuncture on pain and function in patients with chronic knee pain. METHODS: Systematic review and meta-analysis of randomized controlled trials of adequate acupuncture. Computerized databases and reference lists of articles were searched in June 2006. Studies were selected in which adults with chronic knee pain or osteoarthritis of the knee were randomized to receive either acupuncture treatment or a control consisting of sham (placebo) acupuncture, other sham treatments, no additional intervention (usual care), or an active intervention. The main outcome measures were short-term pain and function, and study validity was assessed using a modification of a previously published instrument. RESULTS: Thirteen RCTs were included, of which eight used adequate acupuncture and provided WOMAC outcomes, so were combined in meta-analyses. Six of these had validity scores of more than 50%. Combining five studies in 1334 patients, acupuncture was superior to sham acupuncture for both pain (weighted mean difference in WOMAC pain subscale score = 2.0, 95% CI 0.57-3.40) and for WOMAC function subscale (4.32, 0.60-8.05). The differences were still significant at long-term follow-up. Acupuncture was also significantly superior to no additional intervention. There were insufficient studies to compare acupuncture with other sham or active interventions. CONCLUSIONS: Acupuncture that meets criteria for adequate treatment is significantly superior to sham acupuncture and to no additional intervention in improving pain and function in patients with chronic knee pain. Due to the heterogeneity in the results, however, further research is required to confirm these findings and provide more information on long-term effects.

Acupuncture Analgesia↗