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PubMed2001

Reasons reviewers reject and accept manuscripts: the strengths and weaknesses in medical education reports.

PURPOSE: Scientific journals rely on peer review to maintain the high quality and standards of papers accepted for publication. The purpose of this study was to explore the strengths and weaknesses of medical education reports by analyzing the ratings and written comments given by external reviewers. METHOD: The author conducted a content analysis of reviewers' comments on 151 research manuscripts submitted to the 1997 and 1998 Research in Medical Education conference proceedings. The negative comments on 123 manuscripts that received "questionable, probably exclude" or "definitely exclude" overall ratings from at least one reviewer were evaluated. A similar analysis was performed on reviewers' positive comments for 28 manuscripts recommended unanimously for acceptance. RESULTS: On average, four peers (4.1, SD = 0.97, range = 2-6) reviewed each manuscript. Of those recommended for exclusion, a mean of 2.3 reviewers recommended exclusion and each reviewer wrote a mean of 8.1 (SD = 5.7) reasons. The top ten reasons for rejection were: inappropriate or incomplete statistics; overinterpretation of results; inappropriate or suboptimal instrumentation; sample too small or biased; text difficult to follow; insufficient problem statement; inaccurate or inconsistent data reported; incomplete, inaccurate, or outdated review of the literature; insufficient data presented; and defective tables or figures. The main strengths noted in accepted manuscripts were the importance or timeliness of the problem studies, excellence of writing, and soundness of study design. CONCLUSION: While overstating the results and applying the wrong statistics can be fixed, other problems that the reviewers identified (ignoring the literature, designing poor studies, choosing inappropriate instruments, and writing poor manuscripts) are likely to be fatal flaws warranting rejection.

Curriculum↗
PubMed2002

Assessing professional behavior: yesterday, today, and tomorrow.

PURPOSE: The author interprets the state of the art of assessing professional behavior. She defines the concept of professionalism, reviews the psychometric properties of key approaches to assessing professionalism, conveys major findings that these approaches produced, and discusses recommendations to improve the assessment of professionalism. METHOD: The author reviewed professionalism literature from the last 30 years that had been identified through database searches; included in conference proceedings, bibliographies, and reference lists; and suggested by experts. The cited literature largely came from peer-reviewed journals, represented themes or novel approaches, reported qualitative or quantitative data about measurement instruments, or described pragmatic or theoretical approaches to assessing professionalism. RESULTS: A circumscribed concept of professionalism is available to serve as a foundation for next steps in assessing professional behavior. The current array of assessment tools is rich. However, their measurement properties should be strengthened. Accordingly, future research should explore rigorous qualitative techniques; refine quantitative assessments of competence, for example, through OSCEs; and evaluate separate elements of professionalism. It should test the hypothesis that assessment tools will be better if they define professionalism as behaviors expressive of value conflicts, investigate the resolution of these conflicts, and recognize the contextual nature of professional behaviors. Whether measurement tools should be tailored to the stage of a medical career and how the environment can support or sabotage the assessment of professional behavior are central issues. FINAL THOUGHT: Without solid assessment tools, questions about the efficacy of approaches to educating learners about professional behavior will not be effectively answered.

Education, Medical↗
PubMed1992

Selective decontamination of the digestive tract in the intensive care unit: current status and future prospects.

OBJECTIVE: To evaluate the available data on selective decontamination of the digestive tract. This therapy aims to prevent infection in critically ill patients admitted to ICUs. Microbial carriage in the oropharynx, stomach, and gut; infection; mortality rate; and antibiotic resistance are the outcome events that are being reviewed. DATA SOURCES: Published indices, abstract booklets, and conference proceedings up to the end of 1990. STUDY SELECTION: Sixteen controlled trials of selective decontamination were identified. None of these trials was conducted as a randomized, placebo-controlled, double-blind trial. DATA EXTRACTION: Each of the three authors independently conducted a meta-analysis (thorough review) of the data from the 16 studies. DATA SYNTHESIS: Of the 16 trials, 15 show significant reduction of acquired infection among patients who received selective decontamination. Of the 14 studies that consider carriage of disease-causing microorganisms as an outcome event, 13 demonstrate a reduction in carriage of Gram-negative bacilli. Only ten studies consider mortality as an end-point, of which four demonstrate that the administration of selective decontamination is associated with decreased mortality rates in certain subgroups but not in the overall mortality rate. Of 11 studies that provide data about antibiotic resistance during selective decontamination, ten reported no increase in resistant microorganisms. Selective decontamination has been reported to be effective in controlling an outbreak of multi-resistant microorganisms. CONCLUSIONS: There is a general consensus about the efficacy of selective decontamination in diminishing microbial carriage and acquired infection rates, although conclusions about benefits related to mortality rates vary. Differences in mortality rate are found in the selective decontamination studies of patients with curable diseases, including multitrauma and cardiovascular patients. More data on resistance, collected over a longer period of time, are needed. Practical problems of blinding and the major ecological effect of selective decontamination may explain the lack of a randomized, placebo-controlled, double-blind trial.

Anti-Bacterial Agents↗
PubMed1996

Relationship between the humidity and temperature of inspired gas and the function of the airway mucosa.

OBJECTIVE: To review the available literature on the relationship between the humidity and temperature of inspired gas and airway mucosal function. DATA SOURCES: International computerized databases and published indices, experts in the field, conference proceedings, bibliographies. STUDY SELECTION/DATA EXTRACTION: Two hundred articles/texts on respiratory tract physiology and humidification were reviewed. Seventeen articles were selected from 40 articles for inclusion in the published data verification of the model. Selection was by independent reviewers. Extraction was by consensus, and was based on finding sufficient data. DATA SYNTHESIS: A relationship exists between inspired gas humidity and temperature, exposure time to a given humidity level, and mucosal function. This relationship can be modeled and represented as an inspired humidity magnitude vs. exposure time map. The model is predictive of mucosal function and can be partially verified by the available literature. It predicts that if inspired humidity deviates from an optimal level, a progressive mucosal dysfunction begins. The greater the humidity deviation, the faster the mucosal dysfunction progresses. CONCLUSIONS: A model for the relationship between airway mucosal dysfunction and the combination of the humidity of inspired gas and the duration over which the airway mucosa is exposed to that humidity is proposed. This model suggests that there is an optimal temperature and humidity above which, and below which, there is impaired mucosal function. This optimal level of temperature and humidity is core temperature and 100% relative humidity. However, existing data are only sufficient to test this model for gas conditions below core temperature and 100% relative humidity. These data concur with the model in that region. No studies have yet looked at this relationship beyond 24 hrs. Longer exposure times to any given level of inspired humidity and inspired gas temperatures and humidities above core temperature and 100% relative humidity need to be studied to fully verify the proposed model.

Animals↗
PubMed1998

Tunneling short-term central venous catheters to prevent catheter-related infection: a meta-analysis of randomized, controlled trials.

OBJECTIVE: To evaluate the efficacy of tunneling short-term central venous catheters to prevent catheter-related infections. DATA SOURCES: MEDLINE, EMBASE, conference proceedings, citation review of relevant primary and review articles, personal files, and contact with expert informants. STUDY SELECTION: From a pool of 225 randomized, controlled trials of venous and arterial catheter management, we identified 12 relevant trials and included seven of these trials in the analysis. DATA EXTRACTION: In duplicate, independently, we abstracted data on the population, intervention, outcomes, and methodologic quality. DATA SYNTHESIS: Tunneling decreased bacterial colonization of the catheter by 39% (relative risk of 0.61; 95% confidence interval [CI] of 0.39 to 0.95) and decreased catheter-related sepsis with bacteriologic confirmation by 44% (relative risk of 0.56; 95% CI of 0.31 to 1) in comparison with standard placement. The majority of the benefit in the decreased rate of catheter-sepsis came from one trial at the internal jugular site (relative risk of 0.30, 95% CI of 0.10 to 0.89) and the reduction in risk was not significant when the data from five subclavian catheter trials were pooled (relative risk of 0.71, 95% CI of 0.36 to 1.43). Tunneling was not associated with increased risk of mechanical complications from placement or technical difficulties during placement. However, this outcome was not rigorously evaluated. CONCLUSIONS: Tunneling decreases central venous catheter-related infections. However, current evidence does not support routine tunneling until its efficacy is evaluated at different placement sites and relative to other interventions.

Bacteremia↗
PubMed2002

Factors that alter body fat, body mass, and fat-free mass in pediatric obesity.

PURPOSE: The purpose of this study was to quantify the effects of exercise treatment programs on changes in body mass, fat-free mass, and body fat in obese children and adolescents. METHODS: By using the meta-analytic approach, studies that met the following criteria were included in our analyses: 1) at least six subjects per group; 2) subject groups consisting of children in the 5- to 17-yr age range; 3) pretest and posttest values for either body mass, percent body fat, or fat-free mass (FFM); 4) used exercise as a mode of treatment (e.g., walking, jogging, cycle ergometry, high-repetition resistance exercise, and combinations); 6) training programs >or= 3 wk; 7) full-length publications (not conference proceedings); 8) apparently "healthy" children (i.e., free from endocrine diseases and disorders); and 9) published studies in English language journals only. RESULTS: A total of 120 investigations were located that addressed the issue of exercise as a method of treatment in pediatric obesity. Of those, 30 met our criteria for inclusion. Across all designs and categories, fixed-effects modeling yielded significant decreases in the following dependent variables: 1) percent body fat (mean = 0.70 +/- 0.35; 95% CI = 0.21 to 1.1); 2) FFM (mean = 0.50 +/- 0.38; 95% CI = 0.03 to 0.57); 3) body mass (mean = 0.34 +/- 0.18; 95% CI = 0.01 to 0.46); 4) BMI (mean = 0.76 +/- 0.55; 95% CI = 4.24 to 1.7), and 5) VO2max (mean = 0.52 +/- 0.16; 95% CI = 0.18 to 0.89), respectively. Significant differences were found as a function of the type intervention groups (exercise vs exercise + behavioral modification; P < 0.04); body composition assessment methods (skinfold vs hydrostatic weighing, DEXA, and total body water; P < 0.006); exercise intensity (60-65%, vs >or= 71% VO2max; P < 0.01); duration ( 30 min; P < 0.03); and mode (aerobic vs aerobic + resistance training; P < 0.02). Stepwise linear regression suggested that initial body fat levels (or body mass), type of treatment intervention, exercise intensity, and exercise mode accounted for most of the variance associated with changes in body composition after training. CONCLUSIONS: Exercise is efficacious for reducing selected body composition variables in children and adolescents. The most favorable alterations in body composition occurred with 1) low-intensity, long-duration exercise; 2) aerobic exercise combined with high-repetition resistance training; and 3) exercise programs combined with a behavioral-modification component.

Adolescent↗
PubMed1995

The human immunodeficiency virus epidemic in India. Current magnitude and future projections.

Since the first case of the human immunodeficiency virus (HIV) infection was documented in India in 1986, there has been an explosive increase in HIV transmission. In this review we describe the chronology of the HIV epidemic in India, preliminary information about the clinical presentation of the acquired immunodeficiency syndrome (AIDS), the biological and behavioral aspects of HIV transmission in the Indian setting, and projections regarding the future of the HIV epidemic in India. Using recent data obtained by searching the computerized literature and published abstracts, conference proceedings, and publications from the government of India, we show that India is experiencing a major epidemic of HIV transmission in high-risk populations of commercial sex workers, sexually transmitted disease clinic patients, intravenous drug users, and commercial blood donors. There is also evidence of recent spread of the epidemic from these high-risk groups to other risk groups in India, and from urban centers to rural populations. It is estimated that 1.6 million people are currently infected with HIV in India. At the present rate of transmission, India will have the largest number of HIV-infected individuals of any country in the world by the end of this decade, with more than 5 million infected individuals. Because limited data are available, comprehensive and well-designed epidemiologic surveys are urgently needed to adequately characterize the HIV epidemic in India and to help implement targeted and effective educational and prevention-oriented programs.

Acquired Immunodeficiency Syndrome↗
PubMed1996

Exercise as rehabilitation for cancer patients.

OBJECTIVE: To review the literature on the association of exercise and rehabilitation among cancer patients in order to stimulate research in this field. DATA SOURCES: Computerized literature search of databases (Medline, Psychlit, Sportdiscus, Cinahl) and manual search of journals done to identify all empirical studies on exercise and rehabilitation of cancer patients ever conducted and published in any language on this topic. STUDY SELECTION: Eleven studies found, of these, two were unpublished conference proceedings and could not be obtained, two were doctoral dissertations and seven were published research studies. Of the nine studies reviewed, four were randomized controlled trials, three were quasi-experimental studies, and two were retrospective studies (case-control and cohort in design). All of the studies examined breast cancer patients only. DATA EXTRACTION: Qualitative review conducted since the studies had heterogeneous study designs including the type and form of exercise intervention or measurement, the data collection methods, and the outcome variables. DATA SYNTHESIS: Overall, exercise resulted in an improvement of the physiologic parameters observed, including increases in functional capacity and lean tissue, decreases in percent body fat, nausea and fatigue. Improvements in psychologic indicators of well-being and quality of life also found. CONCLUSIONS: Exercise appears to improve breast cancer patients physiologic and psychologic well being; however, the research studies reviewed here have numerous methodologic limitations and these results must be considered as preliminary evidence only. To improve knowledge of how exercise may help the rehabilitation of all types of cancer patients, future research studies are needed that use a wider sample of cancer patients, a well-designed randomized controlled design, an exercise intervention that more closely reflects true life circumstances, that is of long duration, that measures numerous physiologic and psychologic changes, and that examines exercise recruitment and adherence problems that may occur.

Activities of Daily Living↗
PubMed2004

The efficacy of acamprosate in the maintenance of abstinence in alcohol-dependent individuals: results of a meta-analysis.

BACKGROUND: A number of clinical trials have been undertaken to determine the efficacy of acamprosate in the maintenance of abstinence in alcohol-dependent individuals. However, the reported differences in patient populations, treatment duration, and study endpoints make comparisons difficult. An assessment of the efficacy of treatment with acamprosate was, therefore, undertaken using meta-analytical techniques. METHODS: All randomized, placebo-controlled trials (RCTs) that fulfilled predetermined criteria were identified using (1) a language unrestricted search of 10 electronic databases; (2) a manual search of relevant journals, symposia, and conference proceedings; (3) cross-referencing of all identified publications; (4) personal communications with investigators; and (5) scrutiny of Merck-Santé's internal reports of all European trials. Study quality was assessed, independently, by three blinded workers. Key outcome data were identified; some outcome variables were recalculated to ensure consistency across trials. The primary outcome measure was continuous abstinence at 6 months; abstinence rates were determined by estimating Relative Benefit (RB). RESULTS: A total of 19 published 1 unpublished RCTs were identified that fulfilled the selection criteria; 3 were excluded because the documentation available was insufficient to allow adequate assessment. The remaining 17 studies, which included 4087 individuals, 53% of whom received active drug, were of good quality and were otherwise reasonably comparable. There was no evidence of publication bias. Continuous abstinence rates at 6 months were significantly higher in the acamprosate-treated patients (acamprosate, 36.1%; placebo, 23.4%; RB, 1.47; [95% confidence intervals (CI): 1.29-1.69]; p < 0.001). This effect was observed independently of the method used for assigning missing data. The effect sizes in abstinent rates at 3, 6, and 12 months were 1.33, 1.50, and 1.95, respectively. At 12 months, the overall pooled difference in success rates between acamprosate and placebo was 13.3% (95% CI, 7.8-18.7%; number needed to treat, 7.5). Acamprosate also had a modest but significant beneficial effect on retention (6.01%; [95% CI, 2.90-8.82]; p = 0.0106). CONCLUSION: Acamprosate has a significant beneficial effect in enhancing abstinence in recently detoxified, alcohol-dependent individuals.

Acamprosate↗
PubMed2004

Perinatal outcomes in singletons following in vitro fertilization: a meta-analysis.

OBJECTIVE: To estimate whether singleton pregnancies following in vitro fertilization (IVF) are at higher risk of perinatal mortality, preterm delivery, small for gestational age, and low or very low birth weight compared with spontaneous conceptions in studies that adjusted for age and parity. DATA SOURCES: We searched MEDLINE, BIOSIS, Doctoral Dissertations On-Line, bibliographies, and conference proceedings for studies from 1978-2002 using the terms "in vitro fertilization," "female infertility therapy," and "reproductive techniques" combined with "fetal death," "mortality," "fetal growth restriction," "small for gestational age," "birth weight," "premature labor," "pre-term delivery," "infant," "obstetric," "perinatal," and "neonatal." METHODS OF STUDY SELECTION: Inclusion criteria were singleton pregnancies following IVF compared with spontaneous conceptions, control for maternal age and parity; 1 of the above outcomes; and risk ratios or data to determine them. Study selection and data abstraction were performed in duplicate after removing identifying information. TABULATION, INTEGRATION, AND RESULTS: Fifteen studies comprising 12,283 IVF and 1.9 million spontaneously conceived singletons were identified. Random-effects meta-analysis was performed. Compared with spontaneous conceptions, IVF singleton pregnancies were associated with significantly higher odds of each of the perinatal outcomes examined: perinatal mortality (odds ratio [OR] 2.2; 95% confidence interval [CI] 1.6, 3.0), preterm delivery (OR 2.0; 95% CI 1.7, 2.2), low birth weight (OR 1.8; 95% CI 1.4, 2.2), very low birth weight (OR 2.7; 95% CI 2.3, 3.1), and small for gestational age (OR 1.6; 95% CI 1.3, 2.0). Statistical heterogeneity was noted only for preterm delivery and low birth weight. Sensitivity analyses revealed no significant changes in results. Early preterm delivery, spontaneous preterm delivery, placenta previa, gestational diabetes, preeclampsia, and neonatal intensive care admission were also significantly more prevalent in the IVF group. CONCLUSION: In vitro fertilization patients should be advised of the increased risk for adverse perinatal outcomes. Obstetricians should not only manage these pregnancies as high risk but also avoid iatrogenic harm caused by elective preterm labor induction or cesarean.

Female↗
PubMed2004

Assisted reproductive technology and the incidence of ovarian cancer: a meta-analysis.

OBJECTIVE: To systematically evaluate the available literature regarding the relationship between assisted reproductive technology and ovarian cancer. DATA SOURCES: Computerized search of 6 databases from 1966 (or closest) to present: Cochrane Controlled Trials Register, Cancerlit, CINHAL, Current Contents, PubMed in process (formerly called PreMEDLINE), and MEDLINE. We collected references from the bibliographies of reviews, original research articles, content experts, and conference proceedings to find published and unpublished literature. METHODS OF STUDY SELECTION: Case-control and cohort studies are included. The population of interest is treated infertile women, the control population is untreated infertile women, and the intervention or exposure of interest includes the following fertility medications: clomiphene citrate, gonadotropins, human chorionic gonadotropin, and gonadotropin releasing hormone agonists. The primary outcome is incident, primary ovarian cancer. Three cohort and 7 case-control studies were included in the quantitative analyses. TABULATION, INTEGRATION, AND RESULTS: The Newcastle-Ottawa Quality Assessment Scales were used. Two investigators independently extracted study methods, sources of bias, and outcomes. The following information was recorded: publication information, subject characteristics, intervention information and outcomes. Studies combined were sufficiently homogeneous for quantitative summary. Case-control and cohort data showed a significantly elevated risk for exposure of infertility medications and ovarian cancer in subjects who underwent assisted reproductive technology compared with general population controls (1.52; 95% confidence interval [CI] 1.18 to 1.97). When cases of ovarian cancer were compared with infertile controls for exposure to infertility medications, the odds ratio (0.99; 95% CI 0.67, 1.45) was not elevated. However, cohort data comparing outcome in treated infertile patients with untreated infertile patients suggests that treated patients may tend to a lower incidence of ovarian cancer-odds ratio = 0.67 (95% CI 0.32, 1.41). CONCLUSION: Ovarian cancer does not appear to be increased in treated infertile patients versus untreated infertile patients. Treated infertile patients may have a lower incidence of ovarian cancer than untreated infertile patients.

Adolescent↗
PubMed2004

Systematic review of mifepristone for the treatment of uterine leiomyomata.

OBJECTIVE: To systematically review the effect of mifepristone on uterine leiomyoma size and symptoms and to summarize its adverse effects. DATA SOURCES: A computerized search in MEDLINE, EMBASE, LILACS, and Cochrane databases from 1985 to 2002 and hand searches of conference proceedings from 1995 to 2002 were performed with the search terms "mifepristone" and "leiomyomata" and publication type "clinical trial." METHODS OF STUDY SELECTION: Titles and abstracts were reviewed by 2 authors; there were no areas of disagreement. Inclusion criteria were clinical trials of daily mifepristone for uterine leiomyomata that measured uterine or leiomyoma volume before and after treatment. TABULATION, INTEGRATION, AND RESULTS: Data from each article were abstracted by 2 reviewers. The search identified 6 before-and-after clinical trials involving a total of 166 women with symptomatic uterine leiomyomata. The subjects received 5 to 50 mg/d of mifepristone for 3 to 6 months. No study was placebo-controlled or blinded. Meta-analytic techniques were not performed due to variation in outcome and mifepristone dose. Daily treatment with all doses of mifepristone resulted in reductions in uterine and leiomyoma volumes ranging from 27% to 49% and 26% to 74%, respectively. Mifepristone treatment reduced the prevalence and severity of dysmenorrhea, menorrhagia, and pelvic pressure. Rates of amenorrhea ranged from 63% to 100%. Transient elevations in transaminases occurred in 4%. Endometrial hyperplasia was detected in 10 (28%) of 36 women screened by endometrial biopsy. CONCLUSION: Published trials of mifepristone showed reduction in leiomyoma size and improvement in symptoms. A notable adverse effect of mifepristone was development of endometrial hyperplasia.

Adult↗
PubMed2004

World Health Organization systematic review of screening tests for preeclampsia.

OBJECTIVE: We sought to assess the usefulness of clinical, biophysical, and biochemical tests in the prediction of preeclampsia. DATA SOURCES: The sources of data we used to conduct this review included the computerized databases MEDLINE (1966 to February 2003), EMBASE, Popline, CINAHL, and LILACS plus reference lists, conference proceedings, textbooks, and contact with experts. METHODS OF STUDY SELECTION: All cohort or cross-sectional studies reporting data on the relationship between a predictive test that was performed during pregnancy and the development of preeclampsia were eligible for inclusion, whereas case-control studies were excluded. Eighty-seven (211,369 women) of 7,191 potentially relevant articles met inclusion criteria. We evaluated the methodologic quality for each included study. TABULATION, INTEGRATION, AND RESULTS: Using a standardized protocol, one reviewer selected and extracted data on study characteristics, quality, and accuracy. Data abstracted from each study were arranged in 2 x 2 tables to construct receiver operating characteristics plots (sensitivity against 1 - specificity) and pooled to produce summary likelihood ratios for positive and negative tests results. Moderate predictive accuracy of anticardiolipin antibodies, the presence of bilateral diastolic notches during Doppler ultrasonography, and urinary kallikrein were found in women at low risk of developing preeclampsia. Nevertheless, because the pretest probability of preeclampsia with a positive result was but minimally increased, the clinical use of these tests is limited. Other ultrasonography characteristics and the measurement of fetal and placental peptides showed low predictive accuracy. In populations that were deemed at high risk for preeclampsia, the use of Doppler ultrasonography had low predictive accuracy. No definitive conclusions were possible in the case of many other tests, because the number of studies that met the minimal inclusion criteria was limited. CONCLUSION: As of 2004, there is no clinically useful screening test to predict the development of preeclampsia. Further prospective, longitudinal studies are needed.

Blood Pressure Monitoring, Ambulatory↗
PubMed2004

N-acetylcysteine for the prevention of radiocontrast induced nephropathy: a meta-analysis of prospective controlled trials.

N-acetylcysteine has been recommended for patients with renal insufficiency who are to receive radiocontrast media. However, trials of oral N-acetylcysteine for the prevention of radiocontrast-induced nephropathy have yielded inconsistent results. A systematic review of patient and study characteristics was undertaken to discover possible explanations of the inconsistencies. The databases MEDLINE, EMBASE, and CENTRAL (1966 to March 2003) were searched in all languages, and conference proceedings from several professional societies from the years 1999 to 2003 were also searched. Only prospective controlled trials of oral N-acetylcysteine were included. Risk difference estimates and 95% confidence intervals were calculated. The estimates were examined for evidence of publication bias and heterogeneity. Stratified and meta-regression analyses were used to compare estimates by study and patient characteristics. Identified were 16 studies, 15 published and 1 unpublished. There was no evidence of publication bias, but there was substantial evidence of heterogeneity, thus precluding reliance on a meaningful summary effect estimate. Meta-regression identified several patient and study characteristics, with some evidence of association with study-specific estimates. None of these characteristics, however, formed subsets of studies with results that were homogeneous enough to aggregate. Research on N-acetylcysteine and the incidence of radiocontrast nephropathy is too inconsistent at present to warrant a conclusion on efficacy or a recommendation for its routine use. Identified patient and study characteristics may be responsible for some, but not all, of this inconsistency. A large, randomized, placebo-controlled trial, a pooled analysis of patient-level data, or both may resolve this issue.

Acetylcysteine↗
PubMed2006

Invasive candidiasis in the intensive care unit.

OBJECTIVE: To review epidemiologic trends, advances in diagnosis and susceptibility testing, therapeutic options and guidelines, and management strategies for invasive candidiasis as relevant to the intensive care unit physician. DATA SOURCES, STUDY SELECTION, DATA EXTRACTION, DATA SYNTHESIS: Nonstructured review of peer-reviewed original articles, review articles, abstracts, guidelines, and consensus statements appearing in Medline, major scientific journals, and conference proceedings. CONCLUSIONS: Invasive candidiasis is a problem associated with substantial morbidity and mortality that is highly prevalent in the intensive care unit setting. Recent epidemiologic studies have shown a trend toward increasing numbers of infections and a shift toward infections caused by non-albicans Candida species. Guidelines for the management of these diseases have been published and recommend amphotericin B, fluconazole, or caspofungin as the primary therapeutic option. The choice of agent should depend on local epidemiology and patient factors. The role of newer antifungal agents for this population, such as the new azoles and echinocandins, remains to be determined. Priority areas of research include diagnostics, risk identification, and management strategy assessment such as prophylactic, preemptive, and empirical therapy.

Antifungal Agents↗
PubMed2003

Diabetes in Africa. Diabetes microvascular and macrovascular disease in Africa.

This review on the prevalence and characteristics of diabetes micro- and macrovascular disease in Africa is based on a bibliographical Medline search and diabetes conference proceedings of published data over the past decade. The prevalence of diabetic retinopathy varies from 16 to 77% depending on the duration of diabetes and glycaemic control, with severe retinopathy representing 15% of all cases. At diagnosis, 21-25% of type 2 patients and 9.5% of type 1 patients have retinopathy. The prevalence of nephropathy varies between 32-57% after a mean duration of diabetes of 5-10 years, and 5-28% within the first year following the diagnosis of diabetes. The prevalence of neuropathy varies widely depending on the methodology used. Macrovascular complications of diabetes are considered rare in Africa despite a high prevalence of hypertension. Coronary heart disease may affect 5-8% of type 2 diabetic patients and cardiomyopathy up to 50% of all patients. Lower extremity amputation varies from 1.5 to 7%, and about 12% of all hospitalized diabetic patients have foot ulceration. Neuropathy underlies diabetic foot more often than peripheral vascular disease. In conclusion, whereas microvascular complications of diabetes are highly prevalent and occur early during the course of disease, macrovascular disease is rare. Late diagnosis of diabetes, poor metabolic control and nonstandardized diagnostic procedures rather than genetic predisposition may account for this difference from other populations around the world.

Africa↗
PubMed2003

Treatment of daytime urinary incontinence in children: a systematic review of randomized controlled trials.

PURPOSE: We sought to determine the benefits and harms of interventions for children with daytime urinary incontinence. MATERIALS AND METHODS: Trials of any interventions for children with primary daytime incontinence (the urge syndrome and/or dysfunctional voiding) were identified from the Cochrane Controlled Trials Register, MEDLINE, EMBASE, reference lists of articles, abstracts from conference proceedings and contact with known experts in the field. Once identified, trial quality was assessed, data were extracted and results were expressed in terms of relative risks (RR) with 95% confidence intervals (CI) for individual trials, and summary estimates were obtained using a random effects model. All steps were done by 2 independent reviewers. RESULTS: Randomized trials of terodiline (2 studies), daytime alarms (1), imipramine (1) and biofeedback/oxybutynin (1) involving 383 children were reviewed. No intervention was demonstrated to be effective. In the latter trial, which was the only one to evaluate a currently used intervention, after 9 months of treatment there was no difference in the proportions of children with unimproved daytime wetting with oxybutynin (RR 0.74, CI 0.26 to 2.13) and biofeedback (0.92, 0.59 to 1.43) compared with placebo. CONCLUSIONS: No intervention tested in a trial to date has been proved to be of benefit to children with daytime urinary incontinence.

Adrenergic Uptake Inhibitors↗
PubMed2004

Efficacy of interventions for bronchiolitis in critically ill infants: a systematic review and meta-analysis.

BACKGROUND: Viral bronchiolitis is the leading cause of respiratory failure among infants in the United States. Currently, the mainstay of treatment is supportive care. The effectiveness of treatments used for mechanically ventilated infants with bronchiolitis is unclear. OBJECTIVE: To evaluate the strength of the evidence supporting the use of currently available treatments for critically ill infants with bronchiolitis. DATA SOURCE: We searched PubMed, citations of relevant articles, personal files, and conference proceedings, and we contacted experts in the field. STUDY SELECTION: Randomized, controlled trials evaluating any therapy for bronchiolitis that included children in an intensive care unit. DATA EXTRACTION: Two reviewers independently extracted data and assessed methodologic quality. DATA SYNTHESIS: A total of 2,319 citations were screened, and 16 randomized, controlled trials were included. There were three trials of surfactant, three of ribavirin, three of immune globulin, three of systemic corticosteroids, and one each of vitamin A, interferon, erythropoietin, and heliox. A meta-analysis of the three surfactant studies showed a strong trend toward a decrease in duration of mechanical ventilation of 2.58 days (95% confidence interval, -5.34 to 0.18 days; p =.07) and a significant decrease of 3.3 intensive care unit days (95% confidence interval, -6.38 to -0.23 days; p =.04). A meta-analysis of the three systemic corticosteroid studies showed no overall effect on duration of mechanical ventilation when all three trials were combined (-0.62 day; 95% confidence interval, -2.78 to 1.53 days; p =.57). We identified one published meta-analysis of three ribavirin studies showing a significant decrease in ventilator days with ribavirin (-1.2 days; 95% confidence interval, -0.2 to -3.4 days; p =.2). CONCLUSIONS: Currently, there are no clearly effective interventions available to improve the outcome of critically ill infants with bronchiolitis. Surfactant seems to be a promising intervention, and corticosteroids or ribavirin may also be beneficial.

Bronchiolitis↗