Pit and fissure sealants in high-caries-risk individuals. Acquisition of psychomotor skills in dentistry: an experimental teaching method. Temporal trends in rates of patient harm resulting from medical care. Nonpharmacologic Versus Pharmacologic Treatment of Adult Patients With Major Depressive Disorder: A Clinical Practice Guideline From the American College of Physicians How effective and safe is medical cannabis as a treatment of mental disorders? A systematic review Predictors of treatment acceptance and completion in anorexia nervosa: implications for future study designs. Lack of efficacy of citalopram in children with autism spectrum disorders and high levels of repetitive behavior: citalopram ineffective in children with autism. Measurement error in dietary data: Implications for the epidemiologic study of the diet–disease relationship Acute HIV-1 infection in the Southeastern United States: a cohort study. Is ginger effective for the treatment of irritable bowel syndrome? A double blind randomized controlled pilot trial. Grading the strength of a body of evidence when assessing health care interventions: an EPC update. The CHICO (Children's Cough) Trial protocol: a feasibility randomised controlled trial investigating the clinical and cost-effectiveness of a complex intervention to improve the management of children presenting to primary care with acute respiratory tract infection Efficacy of postural and neck-stabilization exercises for persons with acute whiplash-associated disorders: a systematic review. The effect of an early education program on adult health: the Carolina Abecedarian Project randomized controlled trial. North American Prodrome Longitudinal Study (NAPLS 2): Overview and recruitment The Cochrane Collaboration. Systematic Reviews of Animal Studies; Missing Link in Translational Research? Can antibiotic prescriptions in respiratory tract infections be improved? A cluster-randomized educational intervention in general practice – The Prescription Peer Academic Detailing (Rx-PAD) Study [NCT00272155] The ANTOP study: focal psychodynamic psychotherapy, cognitive-behavioural therapy, and treatment-as-usual in outpatients with anorexia nervosa - a randomized controlled trial Antibiotic Prescribing for Acute Respiratory Tract Infections 12 Months After Communication and CRP Training: A Randomized Trial Some Observations on “Observational” Research Use of text messaging for monitoring sugar-sweetened beverages, physical activity, and screen time in children: a pilot study. Randomized clinical trial comparing family-based treatment with adolescent-focused individual therapy for adolescents with anorexia nervosa. Protocol for systematic reviews of determinants/correlates of obesity-related dietary and physical activity behaviors in young children (preschool 0 to 6 years): evidence mapping and syntheses Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia: diagnosis and treatment. Adherence to protease inhibitors, HIV-1 viral load, and development of drug resistance in an indigent population Occurrence of Community-Acquired Respiratory Tract Infection in Patients Receiving Esomeprazole Pelvic floor muscle training and adjunctive therapies for the treatment of stress urinary incontinence in women: a systematic review Update on the Methods of the U.S. Preventive Services Task Force: Insufficient Evidence A systematic review of anxiety interventions in stroke and acquired brain injury: Efficacy and trial design Effects of high-intensity resistance exercise on bone mineral density and muscle strength of 40-50-year-old women. Anorexia nervosa. Treatment efficacy of cyproheptadine and amitriptyline. World Federation of Societies of Biological Psychiatry (WFSBP) Guidelines for Biological Treatment of Schizophrenia, Part 1: Acute treatment of schizophrenia
This paper examines the evidence demonstrating the effectiveness of sealants in high-caries-risk children and discusses the Research Triangle Institute/University of North Carolina 's ( RTI/UNC ) systematic review . The strict RTI/UNC protocol limited the number of sealant studies that could be included . This analysis exp and ed their criteria to permit additional methods of determining caries risk ( for example , past caries experience , less than two pairs of sound first permanent molars available/child in half-mouth design s ) and outcome measures in addition to DMFS ( that is , percent sealant retention , survival rates , cost-effectiveness , changes in salivary S. mutans levels ) . Nine clinical studies with a r and omized , half-mouth , clinical trial design and seven studies with observational study design s were included . There is good evidence that  sealants can be used efficaciously and effectively in high-risk  children as long as the sealant is retained . Sealants are more effective in preventing further caries and providing cost savings in a shorter time span if placed in children who have high rather than low caries risk Acquisition of psychomotor skills is one of the most important educational tasks in dental education ; yet , there has been little systematic research in this area . This investigation compared a traditional method of teaching psychomotor skills with an experimental method . The investigation was conducted in a pre clinical restorative dentistry laboratory course . Eighty-eight freshman students were r and omly assigned to an experimental ( n = 44 ) or control group ( n = 44 ) ; instructors ( n = 4 ) were r and omly assigned to each group . The control group was taught using the traditional method used at the University of North Carolina School of Dentistry at Chapel Hill ; the experimental group was taught using a guided systematic approach that relied on detailed checklists and exhaustive faculty feedback . Dependent variables measured were quality of performance on laboratory practical examinations , time required to complete practical examinations , and time required to complete the course . Results suggest that this experimental approach has promise for psychomotor skill teaching and learning in dentistry BACKGROUND In the 10 years since publication of the Institute of Medicine 's report To Err Is Human , extensive efforts have been undertaken to improve patient safety . The success of these efforts remains unclear . METHODS We conducted a retrospective study of a stratified r and om sample of 10 hospitals in North Carolina . A total of 100 admissions per quarter from January 2002 through December 2007 were  review  ed in r and om order by teams of  nurse review ers both within the hospitals ( internal review ers ) and outside the hospitals ( external review ers ) with the use of the Institute for Healthcare Improvement 's Global Trigger Tool for Measuring Adverse Events . Suspected harms that were identified on initial review were evaluated by two independent physician review ers . We evaluated changes in the rates of harm , using a r and om-effects Poisson regression model with adjustment for hospital-level clustering , demographic characteristics of patients , hospital service , and high-risk conditions . RESULTS Among 2341 admissions , internal review ers identified 588 harms ( 25.1 harms per 100 admissions ; 95 % confidence interval [ CI ] , 23.1 to 27.2 ) [ corrected ] . Multivariate analyses of harms identified by internal review ers showed no significant changes in the overall rate of harms per 1000 patient-days ( reduction factor , 0.99 per year ; 95 % CI , 0.94 to 1.04 ; P=0.61 ) or the rate of preventable harms . There was a reduction in preventable harms identified by external review ers that did not reach statistical significance ( reduction factor , 0.92 ; 95 % CI , 0.85 to 1.00 ; P=0.06 ) , with no significant change in the overall rate of harms ( reduction factor , 0.98 ; 95 % CI , 0.93 to 1.04 ; P=0.47 ) . CONCLUSIONS In a study of 10 North Carolina hospitals , we found that harms remain common , with little evidence of widespread improvement . Further efforts are needed to translate effective safety interventions into routine practice and to monitor health care safety over time . ( Funded by the Rx Foundation . ) Depressive disorders are a major health care issue and one of the foremost causes of disability in adults around the world , result ing in significant costs to society and health care systems ( 1 ) . The estimated economic burden associated with depression was $ 83.1 billion in 2000 and is probably higher today ( 2 ) . Depressive disorders include major depressive disorder ( MDD ) ; dysthymia ; and subsyndromal depression , including minor depression . Major depressive disorder is the most prevalent depressive disorder , with an estimated lifetime prevalence of 16 % in the United States ( 3 ) . An average of 8 million ambulatory care visits per year result in a primary diagnosis of MDD ( 4 ) . The American Psychiatric Association ( 5 ) defines MDD as depressed mood or loss of pleasure or interest along with other symptoms , including significant change in weight or appetite , insomnia or hypersomnia , psychomotor agitation or retardation nearly every day , fatigue or loss of energy , feelings of worthlessness or excessive or inappropriate guilt , indecisiveness or decreased ability to concentrate , and recurrent thoughts of death or suicide , that last for at least 2 weeks and affect normal functioning . Dysthymia is less severe , but symptoms last for 2 or more years . In contrast , subsyndromal depression is associated with less severe symptoms of depression that do not qualify for MDD or dysthymia diagnoses . The treatment of depression can be characterized by 3 phases ( Figure 1 ) : acute ( 6 to 12 weeks ) , continuation ( 4 to 9 months ) , and maintenance ( 1 year ) ( 7 ) . Relapse is defined as the return of depressive symptoms during the acute or continuation phases and is therefore considered part of the same depressive episode , whereas recurrence is defined as the return of depressive symptoms during the maintenance phase and is considered a new , distinct episode . Response to treatment ( typically defined as 50 % reduction in measured severity ) can be quantified using various tools , such as the Patient Health Question naire-9 ( PHQ-9 ) ( 7 ) or the Hamilton Depression Rating Scale ( HAM-D ) ( 8) . Figure 1 . Phases of treatment of major depression . Adapted from reference 6 . TX = treatment . Various treatment approaches can be used to manage MDD , such as psychotherapy , complementary and alternative medicine ( CAM ) , exercise , and pharmacotherapy . The psychological interventions used to treat depression include acceptance and commitment therapy , cognitive therapy , cognitive behavioral therapy ( CBT ) , interpersonal therapy , and psychodynamic therapies ( Table 1 ) . The CAM treatments include acupuncture , meditation , -3 fatty acids , S-adenosyl-l-methionine ( SAMe ) , St. John 's wort , and yoga . Exercise includes a broad range of activities that can be done for varying duration s , in classes , individually , or in informal groups . For pharmacologic therapy , the scope of this guideline is limited to second-generation antidepressants ( SGAs ) ( selective serotonin reuptake inhibitors , serotonin norepinephrine reuptake inhibitors , and selective serotonin norepinephrine reuptake inhibitors ) . First-generation antidepressants ( tricyclic antidepressants and monoamine oxidase inhibitors ) are very rarely used because SGAs have lower toxicity in overdose than first-generation antidepressants and similar efficacy . Table 1 . Common Psychological Interventions to Treat Depression Guideline Focus and Target Population The purpose of this guideline from the American College of Physicians ( ACP ) is to summarize and grade the evidence on the comparative effectiveness and safety of nonpharmacologic treatments and SGAs ( including serotonin reuptake inhibitors , serotonin norepinephrine reuptake inhibitors , bupropion , mirtazapine , nefazodone , and trazodone ) , alone or in combination , for MDD . The target audience for this guideline includes all clinicians , and the target patient population includes all adults with MDD . These recommendations are based on a background evidence article ( 9 ) and a systematic evidence review sponsored by the Agency for Healthcare Research and Quality ( AHRQ ) ( 6 ) . Methods Systematic Review of the Evidence The systematic evidence review was conducted by the AHRQ 's RTI InternationalUniversity of North Carolina at Chapel Hill Evidence -based Practice Center ( 6 ) . Additional method ological details can be found in the Appendix ) , accompanying background evidence article ( 9 ) , and full report ( 6 ) . Review ers search ed several data bases for studies published in English , German , or Italian from 1 January 1990 through September 2015 . Studies on efficacy were limited to r and omized , controlled trials and systematic review s and meta-analyses , although evidence on harms included observational studies . Review ers combined data when possible using meta- analysis and assessed the risk of bias and quality of studies according to established methods . The study population included adult out patients ( aged 18 years ) with MDD during either an initial or a second treatment attempt who did not remit after an initial adequate trial with an SGA . The review evaluated the following classes of interventions : depression-focused psychotherapy , CAM , exercise , and SGAs . Outcomes assessed included benefits in response ( often defined as 50 % improvement in HAM-D scores ) , remission ( often defined as a HAM-D score 7 ) , speed of response , speed of remission , relapse , quality of life , functional capacity ( as assessed by various scales ) , reduction of suicidality , or reduction of hospitalization . Harms assessed included overall adverse events , withdrawals because of adverse events , serious adverse events , and specific adverse events . Quality of life , functional status , suicidality , and hospitalizations were rarely reported . Grading the Evidence and Developing Recommendations This guideline was developed by the ACP Clinical Guidelines Committee according to the ACP guideline development process , which has been described ( 10 ) . The Clinical Guidelines Committee used the evidence tables in the accompanying systematic review and full report ( 9 ) when reporting the evidence and grade d the recommendations using ACP 's guideline grading system ( Table 2 ) . Table 2 . The American College of Physicians ' Guideline Grading System * Peer Review The AHRQ evidence review was sent to invited peer review ers and posted on the AHRQ Web site for public comments . The guideline was peer- review ed through the journal and was posted online for comments from ACP Governors and Regents . Comparative Benefits of Pharmacologic Versus Nonpharmacologic Treatment Options for Initial Management Refer to Appendix Table 1 and the accompanying systematic review ( 9 ) for additional details of the evidence . Appendix Table 1 . First-Line Treatment for MDD : SGAs Versus Nonpharmacologic Therapies * SGA Versus Psychological Interventions SGA Versus CBT Monotherapy . Moderate- quality evidence from 5 trials ( 1115 ) showed no difference in response when comparing SGAs ( fluoxetine , fluvoxamine , paroxetine , or sertraline ) with CBT in patients with MDD after 8 to 52 weeks of treatment . Low- quality evidence from 3 trials ( 11 , 14 , 15 ) showed no difference between remission rates ( fluoxetine , fluvoxamine , and paroxetine ) and functional capacity ( 14 ) ( fluvoxamine and paroxetine ) for SGAs compared with CBT . Combination Therapy . Low- quality evidence from 2 trials ( 14 , 16 ) showed no difference in response or remission when comparing monotherapy using SGAs ( escitalopram , fluvoxamine , or paroxetine ) with combination therapy using SGAs plus CBT ( problem-solving therapy or telephone-based CBT ) in patients with MDD after 12 to 52 weeks of treatment . Low- quality evidence from 2 trials ( 14 , 16 ) assessed function , and 1 trial showed that patients who received the combination therapy reported more improvement on 3 of 5 work-functioning measures than those who received SGA monotherapy , although clinical ly important differences on these measures are uncertain . SGA Versus Interpersonal Therapy Monotherapy . Low- quality evidence showed no difference in response ( 1 trial ; escitalopram ) ( 17 ) or remission ( 2 trials ; citalopram , escitalopram , or sertraline ) ( 17 , 18 ) for SGAs compared with interpersonal therapy for patients with MDD after 12 weeks of treatment . Combination Therapy . Low- quality evidence from 1 trial ( 19 ) showed increased remission for SGA monotherapy compared with SGA combined with interpersonal therapy ( with nefazodone ) in patients with MDD after 12 weeks of treatment . SGA Versus Psychodynamic Therapies Monotherapy . Low- quality evidence from 1 trial ( 20 ) showed no difference in remission for fluoxetine compared with psychodynamic monotherapy in patients with MDD after 16 weeks of treatment . Low- quality evidence from 2 trials ( 20 , 21 ) showed few differences in functional capacity between the treatments . Combination Therapy . Low- quality evidence from 1 trial ( 21 ) showed no difference in functional capacity for SGA monotherapy compared with SGA plus psychodynamic combination therapy . SGA Versus CAM Interventions SGA Versus Acupuncture Monotherapy . Low- quality evidence from 2 trials ( 22 , 23 ) showed no difference in treatment response when comparing fluoxetine with acupuncture monotherapy for patients with MDD after 6 weeks of treatment . Combination Therapy . Low- quality evidence from 2 trials ( 24 , 25 ) showed that combination therapy of SGAs with acupuncture improved treatment response compared with monotherapy with SGAs ( fluoxetine or paroxetine ) in patients with MDD after 6 weeks of treatment . However , low- quality evidence from 1 trial ( 24 ) showed no difference in remission when comparing paroxetine monotherapy with paroxetine plus acupuncture combination therapy . SGA Versus -3 Fatty Acids Monotherapy . Low- quality evidence from network meta- analysis showed that SGAs ( fluoxetine ) were associated with a greater response than -3 fatty acids in patients with MDD .  SGA Versus SAMe Monotherapy . Low- quality evidence from network meta- analysis showed no difference in response between treatment with escitalopram We conducted a review of systematic review s ( SRs ) and r and omized-controlled trials ( RCTs ) to analyze efficacy and safety of cannabis-based medication in patients with mental disorders . Five data bases were systematic ally search ed ( 2006—August 2018 ) ; 4 SRs ( of 11 RCTs ) and 14 RCTs ( 1629 participants ) were included . Diagnoses were : dementia , cannabis and opioid dependence , psychoses/schizophrenia , general social anxiety , posttraumatic stress disorder , anorexia nervosa , attention-deficit hyperactivity disorder , and Tourette`s disorder . Outcome variables were too heterogeneous to conduct a meta- analysis . A narrative synthesis method was applied . The study quality was assessed using the risk-of-bias tool and SIGN-checklists . THC- and CBD-based medicines , given as adjunct to pharmaco- and psychotherapy , were associated with improvements of several symptoms of mental disorders , but not with remission . Side effects occurred , but severe adverse effects were mentioned in single cases only . In order to provide reliable treatment recommendations , more and larger RCTs with follow-up assessment s , consistent outcome measures and active comparisons are needed CONTEXT There have been very few r and omized controlled treatment studies of anorexia nervosa . OBJECTIVE To evaluate factors leading to nonacceptance and noncompletion of treatment for 2 specific therapies and their combination in the treatment of anorexia nervosa . DESIGN R and omized prospect i ve study . SETTING Weill-Cornell Medical Center , White Plains , NY ; University of Minnesota , Minneapolis ; and Stanford University , Stanford , Calif. Patients One hundred twenty-two patients meeting DSM-IV criteria for anorexia nervosa . INTERVENTIONS Treatment with cognitive-behavioral therapy , fluoxetine hydrochloride , or their combination for 1 year . MAIN OUTCOME MEASURES Dropout rate and acceptance of treatment ( defined as staying in treatment at least 5 weeks ) . RESULTS Of the 122 r and omized cases , 21 ( 17 % ) were withdrawn ; the overall dropout rate was 46 % ( 56/122 ) in the remaining patients . Treatment acceptance occurred in 89 ( 73 % ) of the 122 r and omized cases . Of the 41 assigned to medication alone , acceptance occurred in 23 ( 56 % ) . In the other 2 groups , acceptance rate was differentiated by high and low obsessive preoccupation scores ( rates of 91 % and 60 % , respectively ) . The only predictor of treatment completion was high self-esteem , which was associated with a 51 % rate of treatment acceptance . CONCLUSION Acceptance of treatment and relatively high dropout rates pose a major problem for research in the treatment of anorexia nervosa . Differing characteristics predict dropout rates and acceptance , which need to be carefully studied before comparative treatment trials are conducted CONTEXT Selective serotonin reuptake inhibitors are widely prescribed for children with autism spectrum disorders . OBJECTIVES To determine the efficacy and safety of citalopram hydrobromide therapy for repetitive behavior in children with autism spectrum disorders . DESIGN National Institutes of Health-sponsored r and omized controlled trial . SETTING Six academic centers , including Mount Sinai School of Medicine , North Shore-Long Isl and Jewish Health System , University of North Carolina at Chapel Hill , University of California at Los Angeles , Yale University , and Dartmouth Medical School . PARTICIPANTS One hundred forty-nine volunteers 5 to 17 years old ( mean [ SD ] age , 9.4 [ 3.1 ] years ) were r and omized to receive  citalopram ( n = 73 ) or placebo ( n = 76 ) . Participants had autistic spectrum disorders , Asperger disorder , or pervasive developmental disorder , not otherwise specified ; had illness severity ratings of at least moderate on the Clinical Global Impressions , Severity of Illness Scale ; and scored at least moderate on compulsive behaviors measured with the Children 's Yale-Brown Obsessive Compulsive Scales modified for pervasive developmental disorders . INTERVENTIONS Twelve weeks of citalopram hydrobromide ( 10 mg/5 mL ) or placebo . The mean ( SD ) maximum dosage of citalopram hydrobromide was 16.5 ( 6.5 ) mg/d by mouth ( maximum , 20 mg/d ) . MAIN OUTCOME MEASURES Positive response was defined by a score of much improved or very much improved on the Clinical Global Impressions , Improvement subscale . An important secondary outcome was the score on the Children 's Yale-Brown Obsessive Compulsive Scales modified for pervasive developmental disorders . Adverse events were systematic ally elicited using the Safety Monitoring Uniform Report Form . RESULTS There was no significant difference in the rate of positive response on the Clinical Global Impressions , Improvement subscale between the citalopram-treated group ( 32.9 % ) and the placebo group ( 34.2 % ) ( relative risk , 0.96 ; 95 % confidence interval , 0.61 - 1.51 ; P > .99 ) . There was no difference in score reduction on the Children 's Yale-Brown Obsessive Compulsive Scales modified for pervasive developmental disorders from baseline ( mean [ SD ] , -2.0 [ 3.4 ] points for the citalopram-treated group and -1.9 [ 2.5 ] points for the placebo group ; P = .81 ) . Citalopram use was significantly more likely to be associated with adverse events , particularly increased energy level , impulsiveness , decreased concentration , hyperactivity , stereotypy , diarrhea , insomnia , and dry skin or pruritus . CONCLUSION Results of this trial do not support the use of citalopram for the treatment of repetitive behavior in children and adolescents with autism spectrum disorders . Trial Registration clinical trials.gov Identifier : NCT00086645 Objectives : To examine the effect of measurement error in dietary data on the relationship between diet and body mass index ( BMI ) . To correct for the effect of measurement error on diet– BMI association by using replicate measurements of diet . The effect of measurement error on diet– BMI relationship was simulated , and its implication s are discussed . Design : Prospect i ve study design . Setting : The first and second China Health and Nutrition Survey conducted in 1989 and 1991 , respectively . Subjects : Three thous and , four hundred and seventy-nine adults age 20–45 y at the 1989 survey . Methods : Statistical methods were used to demonstrate the effect of measurement error in dietary data on the diet- BMI association . Results : By using the average of three replicate 24 h dietary recalls , the attenuation of diet- BMI association was reduced substantially . The regression coefficients of fat and energy intakes differed markedly from those computed by using only single measurement of diet . Conclusions : Measurement error in dietary data may significantly attenuate the diet-disease association . Where appropriate , specific emphasis may be needed to address the problem of measurement error in the study of diet-disease relationship . Spnosorship : This research was supported by the National Institute of Health , the Carolina Population Center and the Nutrition Institute , University of North Carolina at Chapel Hill In 1998 a collaboration between Duke University and the University of North Carolina , Chapel Hill ( UNC ) was founded to enhance identification of persons with acute HIV-1 infection ( AHI ) . The Duke-UNC AHI Research Consortium Cohort consists of patients ≥18 years old with a positive nucleic acid amplification test ( NAAT ) and either a negative enzyme immunoassay ( EIA ) test or a positive EIA with a negative/indeterminate Western blot . Patients were referred to the cohort from acute care setting s and state-funded HIV testing sites that use NAAT testing on pooled HIV-1 antibody-negative sample s. Between 1998 and 2010 , 155 patients with AHI were enrolled : 81 ( 52 % ) African-Americans , 63 ( 41 % ) white , non-Hispanics , 137 ( 88 % ) males , 108 ( 70 % ) men who have sex with men ( MSM ) , and 18 ( 12 % ) females . The median age was 27 years ( IQR 22 - 38 ) . Most ( n=138/155 ) reported symptoms with a median duration of 17.5 days . The median nadir CD4 count was 408 cells/mm(3 ) ( IQR 289 - 563 ) ; the median observed peak HIV-1 level was 726,859 copies/ml ( IQR 167,585 - 3,565,728 ) . The emergency department was the most frequent site of initial presentation ( n=55/152 ; 3 missing data ) . AHI diagnosis was made at time of first contact in 62/137 ( 45 % ; 18 missing data ) patients . This prospect ively enrolled cohort is the largest group of patients with AHI reported from the Southeastern United States . The demographics reflect the epidemic of this geographic area with a high proportion of African-Americans , including young black MSM . Highlighting the challenges of diagnosing AHI , less than half of the patients were diagnosed at the first healthcare visit . Women made up a small proportion despite increasing numbers in our clinics OBJECTIVES Ginger is one of the most commonly used herbal medicines for irritable bowel syndrome ( IBS ) but no data exists about its effectiveness . DESIGN Double blind r and omized controlled trial . SETTING University of North Carolina , Chapel Hill , North Carolina , USA . INTERVENTION Forty-five IBS patients were r and omly assigned to three groups : placebo , 1 g of ginger , and 2 g of ginger daily for 28 days . MAIN OUTCOME MEASURES The IBS severity scale ( IBS-SS ) was administered , as well as adequate relief of symptoms scale . A responder was defined as having at least 25 % reduction in IBS-SS post-treatment . RESULTS There were 57.1 % responders to placebo , 46.7 % to 1 g and 33.3 % to 2 g of ginger .  Adequate relief was reported by 53.3 % on placebo and 53.3 % in both ginger groups combined . Side effects were mild and reported by 35.7 % in the placebo and 16.7 % in the ginger groups . CONCLUSIONS This double blind r and omized controlled pilot study suggests ginger is well tolerated but did not perform better than placebo . Larger trials are needed before any definitive conclusions can be drawn OBJECTIVES To revise 2010 guidance on grading the strength of evidence ( SOE ) of the effectiveness of drugs , devices , and other preventive and therapeutic interventions in systematic review s produced by the Evidence -based Practice Center ( EPC ) program , established by the US Agency for Healthcare Research and Quality ( AHRQ ) . STUDY DESIGN AND SETTING A cross-EPC working group review ed authoritative systems for grading SOE [ primarily the approach from the Grading of Recommendations Assessment , Development and Evaluation ( GRADE ) working group ] and conducted extensive discussion s with GRADE and other experts . RESULTS Up date d guidance continues to be conceptually similar to GRADE . Review ers are to evaluate SOE separately for each major treatment comparison for each major outcome . We added reporting bias as a required domain and retained study limitations ( risk of bias ) , consistency , directness , and precision ( and three optional domains ) . Additional guidance covers scoring consistency , precision , and reporting bias , grading bodies of evidence with r and omized controlled trials and observational studies , evaluating single study bodies of evidence , using studies with high risk of bias , and presenting findings with greater clarity and transparency . SOE is grade d high , moderate , low , or insufficient , reflecting review ers ' confidence in the findings for a specific treatment comparison and outcome . CONCLUSION No single approach for grading SOE suits all review s , but a more consistent and transparent approach to reporting summary information will make review s more useful to the broad range of audiences that AHRQ 's work aims to reach . EPC working groups will consider ongoing challenges and modify guidance as needed , on issues such as combining trials and observational studies in bodies of evidence , weighting domains , and combining qualitative and quantitative syntheses Introduction While most respiratory tract infections ( RTIs ) will resolve without treatment , many children will receive antibiotics and some will develop severe symptoms requiring hospitalisation . There have been calls for evidence to reduce uncertainty regarding the identification of children who will and will not benefit from antibiotics .  The aim of this feasibility trial is to test recruitment and the acceptance of a complex behavioural intervention design ed to reduce antibiotic prescribing , and to inform how best to conduct a larger trial . Methods and analysis The CHICO ( Children 's Cough ) trial is a single-centre feasibility cluster r and omised controlled trial ( RCT ) comparing a web-based , within-consultation , behavioural intervention with usual care for children presenting to general practitioner practice s with RTI and acute cough . The trial aims to recruit at least 300 children between October 2014 and April 2015 , in a single area in South West Engl and . Following informed consent , demographic information will be recorded , and symptoms and signs measured . Parents/carers of recruited children will be followed up on a weekly basis to establish symptom duration , re source use and cost of the illness to the parent until the child 's cough has resolved or up to 8 weeks , whichever occurs earlier . A review of medical notes , including clinical history , primary care reconsultations and hospitalisations will be undertaken 2 months after recruitment . The trial feasibility will be assessed by : determining acceptability of the intervention to clinicians and parent/carers ; quantifying differential recruitment and follow-up ; determining intervention fidelity ; the success in gathering the data necessary to conduct a cost-effectiveness analysis ; and collecting data about antibiotic prescribing rates to inform the sample size needed for a fully powered RCT . Ethics and dissemination The study was approved by the North West — Haydock Research Ethics Committee , UK ( reference number : 14/NW/1034 ) . The findings from this feasibility trial will be disseminated through research conferences and peer- review ed journals . Trial registration number IS RCT N23547970 PURPOSE We systematic ally review ed r and omized and quasi-r and omized clinical trials in the literature to assess the efficacy of neck stabilization and postural exercises on pain , neck range of motion , and time off work in adults with acute whiplash-associated disorders . METHODS Electronic data bases , reference lists of relevant Cochrane review s , reference lists of studies selected for inclusion , and tables of contents of relevant journals were systematic ally search ed for r and omized and quasi-r and omized controlled trials . Two independent review ers selected studies for inclusion , assessed method ological quality , and extracted data . Because of the heterogeneity of the interventions , a qualitative synthesis was performed using " levels of evidence " as recommended by van Tulder et al. RESULTS Eight studies representing five clinical trials were selected for inclusion . Two trials were grade d as high quality , two as moderate quality , and one as low quality . Many of these studies had mixed results , demonstrating significant differences on some outcome measures but not on others . CONCLUSIONS There is moderate evidence to support the use of postural exercises for decreasing pain and time off work in the treatment of patients with acute whiplash-associated disorders . However , no evidence exists to support the use of postural exercises for increasing neck range of motion . There is conflicting evidence in support of neck stabilization exercises in the treatment of patients with acute whiplash-associated disorders OBJECTIVES We explored whether a successful r and omized controlled trial of early education , the Carolina Abecedarian Project ( ABC ) , which enrolled infants from 1972 to 1977 at the Frank Porter Graham Child Development Institute in Chapel Hill , North Carolina , improved health outcomes and behaviors by 21 years of age . METHODS ABC r and omized 111 infants to receive an intensive early education program or nutritional supplements and parental counseling alone ; participants have been followed to the present day . We examined the effect of ABC on health outcomes and behavioral risk factors when participants were aged 21 years , and then explored the mediators of this relationship . RESULTS Relative to the control group , the ABC treatment group was previously found to have improved cognition and educational attainment . We found that the intervention also improved heath ( P = .05 ) and health behaviors ( P = .03 ) when participants were aged 21 years . These improvements in behaviors were not mediated by IQ , math and reading scores at 15 years of age , educational attainment , or health insurance . CONCLUSIONS Effective early education programs may improve health and reduce risky health behaviors in adulthood The North American Prodrome Longitudinal Study ( NAPLS ) is a consortium of eight programs focusing on the psychosis prodrome . Funded by the National Institute of Mental Health ( NIMH ) , the sites are located at Emory University , Harvard University , University of Calgary , UCLA , UCSD , University of North Carolina Chapel Hill , Yale University , and Zucker Hillside Hospital . Although the programs initially developed independently , they previously collaborated to combine their historical data sets and to produce a series of analyses on predictors of psychosis in one of the largest sample s of longitudinally followed prodromal subjects worldwide . This led to the development of a five year prospect i ve study " Predictors and Mechanisms of Conversion to Psychosis " , ( also known as NAPLS-2 ) with three major aims : ( 1 ) to prospect ively test the prediction algorithm developed in NAPLS-1 , ( 2 ) to investigate the neuroanatomical , neurophysiological , neurocognitive , and neurohormonal factors that may contribute to the development of psychosis , and ( 3 ) to develop a repository of DNA , RNA , and plasma from participants meeting diagnostic criteria for a clinical high risk ( CHR ) state and from demographically similar healthy subjects . Funded by NIMH in 2008 , NAPLS-2 will generate the largest CHR for psychosis sample with 720 CHR and 240 healthy comparison subjects , and thus will provide statistical power and scientific scope that can not be duplicated by any single site study . This paper describes the overall methodology of the NAPLS-2 project and reports on the ascertainment and demographics at the midway point of the study with ( 360 CHR ) and 180 controls Twenty years ago , you could read all the literature in your field , said reference librarian Kathy Robbins , PhD , MLIS , scanning shelf after shelf of medical journals at the University of Minnesota Bio-Medical Library in Minneapolis . Now , 6000 journal articles are published each day . Merely keeping up with this torrent of information in one 's own specialty is difficult enough . Synthesizing and applying the knowledge to patient care verges on the impossible without some sort of guidance . Fortunately , this guidance is available . Bringing the fruits of new research to the bedside takes at least four levels of review , said Brian Haynes , MD , PhD , professor and chair of the department of clinical epidemiology at McMaster University in Hamilton , Ontario , Canada . Publications such as ACP Journal Club ( of which Haynes is the editor ) collect relevant trials ; the Cochrane Collaboration synthesizes studies of a given research question ; Evidence -Based Medicine Review s integrates the material ; and Clinical Evidence from the British Medical Journal organizes the information according to clinical topic areas , bringing the material closer to practitioners . The goal of the Cochrane Collaboration is to improve the quality of decisions in health care by preparing , maintaining , and promoting the accessibility of systematic review s of the effects of health care interventions . The Cochrane Collaboration has consistently used r and omized , controlled trials ( RCTs ) as the principal focus of its review s. For medical research , The Cochrane Collaboration is a good place to start , said Robbins . If the answer is there , you save time , because the Collaboration has already done the work of search ing journals . The Cochrane Collaboration and Evidence -Based Medicine The Cochrane Collaboration , which is almost a decade old , has a special flavor because its members receive no financial compensation for their contributions . Another noteworthy aspect of the Collaboration is its origin , which stems from the inspiration of one person . Archibald L. Cochrane was a charismatic British epidemiologist whose call for a hard look at how to tell which interventions did more harm than good inspired the formation of a worldwide consortium that prepares systematic review s of r and omized clinical trials . Both evidence -based medicine and the Cochrane Collaboration have roots in the same soil , said Haynes . The origins were n't spontaneous on either side of the Atlantic , said Haynes . Public investment in health care research after World War II had finally produced results that had gone from the laboratory to r and omized , controlled trials . At that point , there was still a gap between evidence and practice . Closing that gap meant knowing which interventions worked and how well . At McMaster , this led to work by Haynes and David Sackett , joined by Alvan Feinstein at Yale , and others , in what was then called critical appraisal of medical literature . ( According to Haynes , the term evidence -based medicine was not introduced until 1991 in an article by Gordon Guyatt in ACP Journal Club . ) In Britain , similar impulses led to the Cochrane Collaboration . Archie Cochrane : A History Kay Dickersin , PhD , codirector of the Collaboration 's New Engl and Center , has written that Archie Cochrane was one of the first to advance the notion that health services must be evaluated on the basis of scientific evidence rather than on clinical impression , anecdotal experience , expert opinion , or tradition .  Cochrane was born in Scotl and in 1909 , graduated from the University of Cambridge , and studied medicine at University Hospital in London . He joined the Royal Army Medical Corps in 1939 and was taken prisoner in 1941 when the German army overran British forces defending the Greek isl and of Crete .  Cochrane spent the rest of the war in prisoner-of-war camps in Greece and Germany , often as the only medical officer serving thous and s of fellow prisoners . Some of the prisoners in the camp in Greece developed edema in their legs , which Cochrane hypothesized was a form of beriberi caused by vitamin B deficiency . He divided his patients into two groups and added yeast to the diet of one group . The intervention worked , and he then persuaded German army officials at the camp to provide yeast to all inmates . It was , Cochrane wrote , his first , worst , and most successful trial ( Cochrane AL . Br Med J [ Clin Res Ed ] . 1984;289:1726 - 7 ) . Later in Germany , when caring for prisoners with tuberculosis , he lamented the lack of hard evidence on whether and when to perform pneumothorax or thoracoplasty . These experiences and observations inspired a postwar career in epidemiology . After the war , Cochrane returned to London and studied statistics under Bradford Hill ( who would publish the first major r and omized clinical trial , on streptomycin to treat pulmonary tuberculosis , in 1948 ) . Cochrane settled in Cardiff , Wales , where over the next 20 years , he studied the epidemiology of tuberculosis and pneumoconiosis . In 1972 , Cochrane published Effectiveness and Efficiency : R and om Reflections on Health Services , in which he argued that r and omized clinical trials could separate valuable interventions from harmful or useless ones . Seven years later , he wrote : It is surely a great criticism of our profession that we have not organized a critical summary , by specialty or subspecialty , adapted periodically , of all relevant r and omized , controlled trials . Cochrane was especially critical of obstetrics and gynecology , which had failed to evaluate properly new innovations in the field ( such as the move to universal hospital delivery for childbirth and the introduction of Papanicolaou smears for cancer screening of the cervix ) before widespread introduction . Iain Chalmers , an obstetrician in Cardiff who knew Cochrane and his work , found Cochrane 's ideas compelling . If one is going to make rational use of limited re sources for health care , one needs to know which of the many things that people are doing within health care have been shown in reliable research studies to be more likely to do good than harm , said Chalmers recently . And the search for and analysis of the evidence needed to provide this information base should be systematic . The First RCT Registry Thus inspired , Chalmers set out in 1974 to create a comprehensive register of all r and omized clinical trials in perinatal medicine ( pregnancy through postpartum day 28 ) . At the time , a MEDLINE search might have retrieved barely half of all trials published after 1965 . Chalmers directed a team of volunteers in h and search ing 50 journals , going as far back as 1940 . They accumulated 3500 trial reports , and their compilation result ed in the publication in 1985 of A Classified Bibliography of Controlled Trials in Perinatal Medicine , 19401984 . Rapid progress in the field , however , meant that the volume was out of date almost immediately after it was printed , said Dickersin . A regularly up date d , electronic version first appeared in 1988a harbinger of later storage and distribution systems ( Dickersin K , Manheimer E. Clin Obstet Gynecol . 1998;41:315 - 31 ) . Further analytic work by Chalmers and others based on this bibliographic material yielded several volumes on perinatal medicine , including a 350-page paperback , Guide to Effective Care in Pregnancy and Childbirth , that presented the conclusions of the full versions in ways immediately useful to women using the maternity services . The systematic review s that were initially published on paper in three books were then kept up to date in a semi-annual electronic publication called The Oxford Data base of Perinatal Trials . Birth of the Cochrane Collaboration In 1993 , Chalmers and an international group of about 70 others jointly announced the formation of the Cochrane Collaboration to prepare , maintain , and disseminate systematic review s of the effects of health care interventions . Dickersin was the principal U.S. representative at the inaugural meeting . The Collaboration 's systematic review s entail exhaustive literature search es and the selection and analysis of studies based on explicit , prespecified criteria , sometimes , but not always , using meta-analyses , which are formal , mathematical combinations of numerical results . With the traditional review article , there are no guidelines about how to do it and no transparency for the reader . You ca n't tell if they 've really plowed through the literature or just picked over their file cabinets , said Dickersin , now associate professor of community health at Brown University School of Medicine in Providence , Rhode Isl and . Meta-analyses , to be good , must be of high quality and appropriate . Sometimes they may lump data together from both r and omized and observational trials or exhibit other biases . When poor meta-analyses are associated with systematic review s , people may assume guilt by association . Clinical practice guidelines may be an outgrowth of systematic review s , but they should be done by different peopleclinicians and professional organizations , she said . How Cochrane Works The Collaboration is made up of review groups , centers , fields , methods groups , and the consumer network . The review groups search for , collect , and analyze RCTs relating to specific health conditions . The 15 centers that constitute the Collaboration are geographically dispersed across 13 countries . In addition to coordinating the review activities within their region , each center also performs specialized functions . The San Francisco Center , for instance , advises on the electronic feedback and peer- review system . An elected 12-member steering group oversees the entire organization , supported by a small secretariat based in Oxford . The real work of the Collaboration takes place in the review groups , building on the model established by Chalmers ' work on perinatal medicine . Initiative for review s generally comes from members who suggest topics to the groups , explained Lisa A. Bero , PhD , associate professor of health policy studies Background The method ological quality of animal studies is an important factor hampering the translation of results from animal studies to a clinical setting . Systematic review s of animal studies may provide a suitable method to assess and thereby improve their method ological quality . Objectives The aims of this study were : 1 ) to evaluate the risk of bias assessment in animal-based systematic review s , and 2 ) to study the internal validity of the primary animal studies included in these systematic review s. Data Sources We systematic ally search ed Pubmed and Embase for SRs of pre clinical animal studies published between 2005 and 2012 . Results A total of 91 systematic review s met our inclusion criteria . The risk of bias was assessed in 48 ( 52.7 % ) of these 91 systematic review s. Thirty-three ( 36.3 % ) SRs provided sufficient information to evaluate the internal validity of the included studies . Of the evaluated primary studies , 24.6 % was r and omized , 14.6 % reported blinding of the investigator/caretaker , 23.9 % blinded the outcome assessment , and 23.1 % reported drop-outs . Conclusions To improve the translation of animal data to clinical practice , systematic review s of animal studies are worthwhile , but the internal validity of primary animal studies needs to be improved . Furthermore , risk of bias should be assessed by systematic review s of animal studies to provide insight into the reliability of the available evidence Background More than half of all antibiotic prescriptions in general practice are issued for respiratory tract infections ( RTIs ) , despite convincing evidence that many of these infections are caused by viruses . Frequent misuse of antimicrobial agents is of great global health concern , as we face an emerging worldwide threat of bacterial antibiotic resistance . There is an increasing need to identify determinants and patterns of antibiotic prescribing , in order to identify where clinical practice can be improved . Methods / Design Approximately 80 peer continuing medical education ( CME ) groups in southern Norway will be recruited to a cluster r and omized trial . Participating groups will be r and omized either to an intervention- or a control group . A multifaceted intervention has been tailored , where key components are educational outreach visits to the CME-groups , work-shops , audit and feedback . Prescription Peer Academic Detailers ( Rx-PADs ) , who are trained GPs , will conduct the educational outreach visits . During these visits , evidence -based recommendations of antibiotic prescriptions for RTIs will be presented and software will be h and ed out for installation in participants PCs , enabling collection of prescription data . These data will subsequently be linked to corresponding data from the Norwegian Prescription Data base ( NorPD ) . Individual feedback reports will be sent all participating GPs during and one year after the intervention . Main outcomes are baseline proportion of inappropriate antibiotic prescriptions for RTIs and change in prescription patterns compared to baseline one year after the initiation of the tailored pedagogic intervention . Discussion Improvement of prescription patterns in medical practice is a challenging task . A thorough evaluation of guidelines for antibiotic treatment in RTIs may impose important benefits , whereas inappropriate prescribing entails substantial costs , as well as undesirable consequences like development of antibiotic resistance . Our hypothesis is that an educational intervention program will be effective in improving prescription patterns by reducing the total number of antibiotic prescriptions , as well as reducing the amount of broad-spectrum antibiotics , with special emphasis on macrolides Background Anorexia nervosa is a serious eating disorder leading to high morbidity and mortality as a result of both malnutrition and suicide . The seriousness of the disorder requires extensive knowledge of effective treatment options . However , evidence for treatment efficacy in this area is remarkably weak . A recent Cochrane review states that there is an urgent need for large , well- design ed treatment studies for patients with anorexia nervosa . The aim of this particular multi-centre study is to evaluate the efficacy of two st and ardized outpatient treatments for patients with anorexia nervosa :  focal psychodynamic ( FPT ) and cognitive behavioural therapy ( CBT ) . Each therapeutic approach is compared to a " treatment-as-usual " control group . Methods / Design 237 patients meeting eligibility criteria are r and omly and evenly assigned to the three groups – two intervention groups ( CBT and FPT ) and one control group . The treatment period for each intervention group is 10 months , consisting of 40 sessions respectively . Body weight , eating disorder related symptoms , and variables of therapeutic alliance are measured during the course of treatment . Psychotherapy sessions are audiotaped for adherence monitoring . The treatment in the control group , both the dosage and type of therapy , is not regulated in the study protocol , but rather reflects the current practice of established outpatient care . The primary outcome measure is the body mass index ( BMI ) at the end of the treatment ( 10 months after r and omization ) . Discussion The study design surmounts the disadvantages of previous studies in that it provides a r and omized controlled design , a large sample size , adequate inclusion criteria , an adequate treatment protocol , and a clear separation of the treatment conditions in order to avoid contamination . Nevertheless , the study has to deal with difficulties specific to the psychopathology of anorexia nervosa . The treatment protocol allows for dealing with the typically occurring medical complications without dropping patients from the protocol . However , because patients are difficult to recruit and often ambivalent about treatment , a drop-out rate of 30 % is assumed for sample size calculation . Due to the ethical problem of denying active treatment to patients with anorexia nervosa , the control group is defined as " treatment-as-usual".Trial registration Current Controlled Trials IS RCT PURPOSE C-reactive-protein ( CRP ) is useful for diagnosis of lower respiratory tract infections ( RTIs ) . A large international trial documented that Internet-based training in CRP point-of-care testing , in enhanced communication skills , or both reduced antibiotic prescribing at 3 months , with risk ratios ( RRs ) of 0.68 , 0.53 , 0.38 , respectively . We report the longer-term impact in this trial . METHODS A total of 246 general practice s in 6 countries were cluster-r and omized to usual care , Internet-based training on CRP point-of-care testing , Internet-based training on enhanced communication skills and interactive booklet , or both interventions combined . The main outcome was antibiotic prescribing for RTIs after 12 months . RESULTS Of 228 practice s providing 3-month data , 74 % provided 12-month data , with no demonstrable attrition bias . Between 3 months and 12 months , prescribing for RTIs decreased with usual care ( from 58 % to 51 % ) , but increased with CRP training ( from 35 % to 43 % ) and with both interventions combined ( from 32 % to 45 % ) ; at 12 months , the adjusted RRs compared with usual care were 0.75 ( 95 % CI , 0.51 - 1.00 ) and 0.70 ( 95 % CI , 0.49 - 0.93 ) , respectively . Between 3 months and 12 months , the reduction in prescribing with communication training was maintained ( 41 % and 40 % , with an RR at 12 months of 0.70 [ 95 % CI , 0.49 - 0.94 ] ) . Although material s were provided for free , clinicians seldom used booklets and rarely used CRP point-of-care testing . Communication training , but not CRP training , remained efficacious for reducing prescribing for lower RTIs ( RR = 0.7195 % CI , 0.45 - 0.99 , and RR = 0.76 ; 95 % CI , 0.47 - 1.06 , respectively ) , whereas both remained efficacious for reducing prescribing for upper RTIs ( RR = 0.60 ; 95 % CI , 0.37 - 0.94 , and RR = 0.58 ; 95 % CI , 0.36 - 0.92 , respectively ) . CONCLUSIONS Internet-based training in enhanced communication skills remains effective in the longer term for reducing antibiotic prescribing . The early improvement seen with CRP training wanes , and this training becomes ineffective for lower RTIs , the only current indication for using CRP testing Evidence -based medicine ( EBM ) ranks different medical research methods on a hierarchy , at the top of which are r and omized controlled trials ( RCTs ) and systematic review s or meta-analyses of RCTs . Any study that does not r and omly assign patients to a treatment or a control group is automatically placed at a lower level on the hierarchy . This article argues that what matters is whether the treatment and control groups are similar with respect to potential confounding factors , not whether they got that way through r and omization . Moreover , nonr and omized studies tend to have other characteristics that make them useful sources of evidence , in that they tend to last longer and to enroll more patients than do r and omized trials . Replacing the sharp dichotomy between r and omized and nonr and omized studies with a continuum from “ clean ” studies ( which have high internal validity but whose results do not readily generalize to clinical practice ) to pragmatic studies ( which are design ed to more closely reflect clinical practice ) would also make a place for outcomes research and research using clinical data bases , which are not included in the current hierarchy of evidence but which can provide important information about the safety and efficacy of treatments OBJECTIVE To examine acceptability , attrition , adherence , and preliminary efficacy of mobile phone short message service ( SMS ; text messaging ) for monitoring healthful behaviors in children . DESIGN All r and omized children received a brief psychoeducational intervention . They then either monitored target behaviors via SMS with feedback or via paper diaries ( PD ) or participated in a no-monitoring control ( C ) for 8 weeks . SETTING University of North Carolina at Chapel Hill . PARTICIPANTS Fifty-eight children ( age 5 - 13 ) and parents participated ; 31 completed ( SMS : 13/18 , PD : 7/18 , C : 11/22 ) . INTERVENTION Children and parents participated in a total of 3 group education sessions ( 1 session weekly for 3 weeks ) to encourage increasing physical activity and decreasing screen time and sugar-sweetened beverage consumption . MAIN OUTCOME MEASURES Treatment acceptability , attrition , and adherence to self-monitoring . ANALYSIS Descriptive statistics and nonparametric tests were used to analyze differences across time and group . RESULTS Children in SMS had somewhat lower attrition ( 28 % ) than both PD ( 61 % ) and C ( 50 % ) , and significantly greater adherence to self-monitoring than PD ( 43 % vs 19 % , P < .02 ) . CONCLUSIONS AND IMPLICATION S Short message service may be a useful tool for self-monitoring healthful behaviors  in children , although the efficacy of this approach needs further study . Implication s suggest that novel technologies may play a role in improving health CONTEXT Evidence -based treatment trials for adolescents with anorexia nervosa are few . OBJECTIVE To evaluate the relative efficacy of family-based treatment ( FBT ) and adolescent-focused individual therapy ( AFT ) for adolescents with anorexia nervosa in full remission . DESIGN R and omized controlled trial . SETTING Stanford University and The University of Chicago ( April 2005 until March 2009 ) . PARTICIPANTS One hundred twenty-one participants , aged 12 through 18 years , with DSM-IV diagnosis of anorexia nervosa excluding the amenorrhea requirement . Intervention Twenty-four outpatient hours of treatment over 12 months of FBT or AFT . Participants were assessed at baseline , end of treatment ( EOT ) , and 6 months ' and 12 months ' follow-up posttreatment . MAIN OUTCOME MEASURES Full remission from anorexia nervosa defined as normal weight ( ≥95 % of expected for sex , age , and height ) and mean global Eating Disorder Examination score within 1 SD of published means . Secondary outcome measures included partial remission rates ( > 85 % of expected weight for height plus those who were in full remission ) and changes in body mass index percentile and eating-related psychopathology . RESULTS There were no differences in full remission between treatments at EOT . However , at both the 6- and 12-month follow-up , FBT was significantly superior to AFT on this measure . Family-based treatment was significantly superior for partial remission at EOT but not at follow-up . In addition , body mass index percentile at EOT was significantly superior for FBT , but this effect was not found at follow-up . Participants in FBT also had greater changes in Eating Disorder Examination score at EOT than those in AFT , but there were no differences at follow-up . CONCLUSION Although both treatments led to considerable improvement and were similarly effective in producing full remission at EOT , FBT was more effective in facilitating full remission at both follow-up points . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00149786 Background The aim of these review s is to inform the design and content of interventions to reduce obesity in young children . The behaviors that are associated with obesity/overweight have been studied extensively ; however , the factors associated with these behaviors in young children ( 0 to 6 years ) have not been systematic ally review ed . Over the past few years the focus of obesity prevention has shifted to preschool children because of the high prevalence of obesity at school entry and recognition that habits formed in early life could track into adulthood . In order to develop effective interventions and change behavior , it is important to underst and the factors that are associated with those behaviors . For example , we need to underst and whether it would be more important to target the family , childcare setting s or the wider environment and identify the most effective way of changing these energy balance related behaviors . Methods / Design Quantitative ( intervention and observational ) and qualitative literature on determinants/correlates of fruit and vegetable intake , sugar sweetened beverage and other unhealthy diet intake , and physical activity and sedentary behaviors in young children will be systematic ally identified , mapped and review ed . A common search strategy ( no language or period restrictions ) will be used to identify papers from eight electronic data bases and this will be supplemented by h and - search ing . Next , studies in developed countries that examine the factors associated with these behaviors in children aged 0 to 6 years ( at baseline ) will be screened and mapped descriptively followed by in-depth data extraction , quality assessment and synthesis . Data from quantitative studies will be summarized using either forest plots or harvest plots and narrative synthesis , and qualitative studies using thematic analysis . Qualitative evidence will be integrated with the quantitative evidence , using a parallel synthesis approach , to provide a deeper underst and ing of effective strategies to influence these energy balance related behaviors . Discussion In addition to updating and mapping current research , these review s will be the first to comprehensively synthesize and integrate both the quantitative and qualitative evidence pertaining to determinants/correlates/barriers/facilitators of obesity related behaviors in this young age group ( 0 to 6 years ) with the aim of informing future interventions . Systematic review registration International Prospect i ve Register for Systematic Review s ( PROSPERO ) Registration number : BACKGROUND Ventilator-associated pneumonia ( VAP ) is an important cause of morbidity and mortality in ventilated critically ill patients . Despite a large amount of research evidence , the optimal diagnostic and treatment strategies for VAP remain controversial . PURPOSE The aim of this study was to develop evidence -based clinical practice guidelines for the diagnosis and treatment of VAP . Data sources include Medline , EMBASE , Cumulative Index to Nursing and Allied Health Literature , and the Cochrane Data base of Systematic Review s and Register of Controlled Trials . STUDY SELECTION The authors systematic ally search ed for all relevant r and omized controlled trials and systematic review s on the diagnosis and treatment of VAP in mechanically ventilated adults that were published from 1980 to October 1 , 2006 . DATA EXTRACTION Independently and in duplicate , the panel critically appraised each published trial . The effect size , confidence intervals , and homogeneity of the results were scored using predefined definitions . The full guideline development panel arrived at a consensus for scores on safety , feasibility , and economic issues . LEVELS OF EVIDENCE Based on the scores for each topic , the following statements of recommendation were used : recommend , consider , do not recommend , and no recommendation because of insufficient or conflicting evidence . DATA SYNTHESIS For the diagnosis of VAP in immunocompetent patients , we recommend that endotracheal aspirates with nonquantitative cultures be used as the initial diagnostic strategy . When there is a suspicion of VAP , we recommend empiric antimicrobial therapy ( in contrast to delayed or culture directed therapy ) and appropriate single agent antimicrobial therapy for each potential pathogen as empiric therapy for VAP . Choice of antibiotics should be based on patient factors and local resistance patterns . We recommend that an antibiotic discontinuation strategy be used in patients who are treated of suspected VAP . For patients who receive adequate initial antibiotic therapy , we recommend 8 days of antibiotic therapy . We do not recommend nebulized endotracheal tobramycin or intratracheal instillation of tobramycin for the treatment of VAP . CONCLUSION We present evidence -based recommendations for the diagnosis and treatment of VAP . Implementation of these recommendations into clinical practice may lessen the morbidity and mortality of patients who develop VAP Objective To examine the relationship between adherence , viral suppression and antiretroviral resistance in HIV-infected homeless and marginally housed people on protease inhibitor ( PI ) therapy .  Design and setting A cross-sectional analysis of subjects in an observational prospect i ve cohort systematic ally sample d from free meal lines , homeless shelters and low-income , single-room occupancy ( SRO ) hotels . Participants Thirty-four HIV-infected people with a median of 12 months of PI therapy .  Main outcomes Adherence measured by periodic unannounced pill counts , electronic medication monitoring , and self-report ; HIV RNA viral load ; and HIV-1 genotypic changes associated with drug resistance . Results Median adherence was 89 , 73 , and 67 % by self-report , pill count , and electronic medication monitor , respectively . Thirty-eight per cent of the population had over 90 % adherence by pill count . Depending on the measure , adherence explained 36–65 % of the variation in concurrent HIV RNA levels . The three adherence measures were closely related . Of 20 genotyped patients who received a new reverse transcriptase inhibitor ( RTI ) when starting a PI , three had primary protease gene substitutions . Of 12 genotyped patients who received a PI without a new RTI , six had primary protease gene substitutions ( P < 0.03 ) . Conclusion A substantial proportion of homeless and marginally housed individuals had good adherence  to PI therapy . A strong relationship was found between independent methods of measuring adherence and concurrent viral suppression . PI resistance was more closely related to the failure to change RTI when starting a PI than to the level of adherence Abstract Background : A potential causal association between an increase in gastric pH and a risk of community-acquired respiratory tract infection ( RTI ) , specifically pneumonia , has been debated in relation to the use of potent gastric acid-suppressive medication . Objective : To investigate the occurrence of community-acquired RTI , including pneumonia , in patients receiving esomeprazole versus placebo and other acid-suppressive agents in r and omized clinical trials . Methods : The AstraZeneca ARIADNE safety data base was search ed for comparative , controlled phase II – IV r and omized , blinded clinical studies with esomeprazole and st and ard reporting of all adverse events ( AEs ) . Pooled AE data were presented according to treatment comparison ( esomeprazole versus placebo , esomeprazole 40 mg versus 20 mg daily , esomeprazole versus omeprazole , lansoprazole and /or ranitidine , respectively ) . Frequency and relative risk ( RR ) , with 99 % confidence interval ( CI ) and adjustment for time on treatment , were calculated for the following four AE categories : all RTIs ; signs and symptoms potentially indicating RTI ; lower RTI ; and pneumonia . Results : Thirty-one studies were identified , in which 16 583 patients received esomeprazole and 12 044 patients received either placebo or comparator acid-suppressive drugs . The occurrence of all four categories of AEs was similar between esomeprazole and placebo ( all RTIs : 9.2 % versus 8.5 % ; signs and symptoms of RTI : 1.8 % versus 1.8 % ; lower RTI : 1.6 % versus 1.5 % ; and pneumonia : 0.2 % in both groups ) . The RR estimates were as follows : all RTIs , 0.93 ( 99 % CI 0.78 , 1.11 ) ; signs and symptoms of RTI , 0.85 ( 99 % CI 0.57 , 1.27 ) ; lower RTI , 0.92 ( 99 % CI 0.59 , 1.42 ) ; and pneumonia , 0.94 ( 99 % CI 0.29 , 3.07 ) . The distribution of RTIs by patient sex and age showed a similar pattern in esomeprazole and placebo-treated patients . The comparisons of esomeprazole with the other comparator acid-suppressive drugs showed a similar pattern with only minor numerical differences in the occurrence of RTI between the drugs . There were no significant between-group differences with esomeprazole versus placebo for all four categories of AEs according to esomeprazole dosage , treatment indication and duration of treatment . Conclusions : This pooled analysis found no causal association between acid-suppressive therapy with esomeprazole and increased risk of community-acquired RTI , including pneumonia , in patients receiving this agent for gastric acid-related disorders Background Stress urinary incontinence ( SUI ) is a prevalent and costly condition which may be treated surgically or by physical therapy . The aim of this review was to systematic ally assess the literature and present the best available evidence for the efficacy and effectiveness of pelvic floor muscle training ( PFMT ) performed alone and together with adjunctive therapies ( eg biofeedback , electrical stimulation , vaginal cones ) for the treatment of female SUI . Methods All major electronic sources of relevant information were systematic ally search ed to identify peer- review ed English language abstract s or papers published between 1995 and 2005 . R and omised controlled trials ( RCTs ) and other study design s eg non-r and omised trials , cohort studies , case series , were considered for this review in order to source all the available evidence relevant to clinical practice . Studies of adult women with a urodynamic or clinical diagnosis of SUI were eligible for inclusion . Excluded were studies of women who were pregnant , immediately post-partum or with a diagnosis of mixed or urge incontinence . Studies with a PFMT protocol alone and in combination with adjunctive physical therapies were considered . Two independent review ers assessed the eligibility of each study , its level of evidence and the method ological quality . Due to the heterogeneity of study design s , the results are presented in narrative format . Results Twenty four studies , including 17 RCTs and seven non- RCTs , met the inclusion criteria . The method ological quality of the studies varied but lower quality scores did not necessarily indicate studies from lower levels of evidence . This review found consistent evidence from a number of high quality RCTs that PFMT alone and in combination with adjunctive therapies is effective treatment for  women  with  SUI  with rates of ' cure ' and ' cure/improvement ' up to 73 % and 97 % respectively . The contribution of adjunctive therapies is unclear and there is limited evidence about treatment outcomes in primary care setting s. Conclusion There is strong evidence for the efficacy of physical therapy for the treatment for SUI in women but further high quality studies are needed to evaluate the optimal treatment programs and training protocol s in subgroups of women and their effectiveness in clinical practice The U.S. Preventive Services Task Force ( USPSTF ) is an independent panel of experts that is convened and supported by the Agency for Healthcare Research and Quality ( AHRQ ) . The U.S. Congress has charged the USPSTF to review the scientific evidence for clinical preventive services and develop evidence -based recommendations about their delivery . In its recommendations , the USPSTF seeks to maximize population health benefits while minimizing harms . The target audience for USPSTF recommendations is primary care clinicians , but the recommendations are widely used by others as well ( 1 ) . The USPSTF processes and methods are continually examined , and recent up date s have been published ( 13 ) . The USPSTF Procedure Manual is posted on the AHRQ Web site ( 4 ) . In this issue , the USPSTF reports that it concluded that the evidence to determine whether the benefits of skin cancer screening outweigh the harms was insufficient ( 5 ) . No recommendation was made , and no letter grade was assigned . Instead , the USPSTF issued an I statement ( 2 ) . Evidence is often found to be insufficient for topics considered by the USPSTF . Even for screening topics that pertain to all or a large majority of adults , children , or adolescents , evidence is often insufficient ( Table 1 ) ( 6 ) . Table 1 . Insufficient Evidence Statements for Screening of Large Population Subgroups The release of the I statement for skin cancer screening provides an opportunity for the USPSTF to describe its plan to exp and the kinds of information it commissions to be collected and reported routinely by Evidence -based Practice Centers , to describe the process that led to selection of this information , and to illustrate the uses of the information with examples . Problem Statement Primary care physicians and their professional societies expressed frustration with the frequency with which the USPSTF concluded that evidence is insufficient to make a recommendation . In the past , the USPSTF coupled this conclusion with a recommendation worded as follows : the USPSTF concludes that the evidence is insufficient to recommend for or against routine provision of xxx service . Clinicians pointed out that this wording is not a recommendation . Anecdotally , the statement was characterized as useless and sometimes as worse than useless . In focus groups of practicing primary care providers , a common request was for USPSTF guidance on a course of action with individual patients in situations in which evidence about net benefit is insufficient . Professional society representatives reinforced the need for guidance . The USPSTF and other bodies have generally held that the strongest argument for providing an intervention is based on scientific evidence from multiple large , well-conducted , r and omized clinical trials ( RCTs ) . However , for most clinical preventive services , this st and ard of evidence is unattainable . Requirements for RCTs of behavioral counseling interventions are especially problematic because the study interventions in gold-st and ard RCTs may be artificial . Tucker and Roth ( 7 ) discuss this problem in the context of behavioral interventions for substance abuse . They point out that requiring fidelity in treatment delivery in a gold-st and ard RCT may eliminate the context ual aspects of the treatment experience and the adaptation of treatment to individual needs that underlies treatment success . Requiring a no-treatment or usual-treatment control condition may produce insurmountable barriers to recruitment . Requiring a control condition with the same number of contact hours as the treatment condition can compromise retention . For different reasons , the conduct of RCTs for preventive services delivered to infants , children , and adolescents also presents challenges . For some preventive services , the long timeline required to improve health outcomes makes RCTs impractical . Consensus is lacking about the appropriate outcomes for preventive interventions in children , although agreement is universal that decreasing mortality is not the only goal of preventive services provided to this age group . Finally , many valuable preventive interventions will never be evaluated in an RCT because a trial would be too expensive , recruiting enough participants is not feasible , or investigator interest or funding is lacking . Acknowledging the Contribution of Non- RCT Evidence and Persisting Issues Recognizing the paucity of evidence from RCTs , the USPSTF and other groups consider evidence from non- RCT study design s ( such as cohort , cross-sectional , casecontrol , or quasi-experimental ) as a st and ard strategy . Use of an analytic framework , which is an organizing principle for all recent or current USPSTF systematic review s , permits incorporation of evidence from studies with a variety of design s and yields certainty that can in theory approach the certainty of evidence derived from RCTs . In constructing an analytic framework , clinical problems are conceptualized in terms of a sequence of key questions ( 8) . A systematic review is generally done to answer each key question . When considered together , the key question evidence forms a chain of evidence that permits firm conclusions about net benefit . In the case of skin cancer , notwithst and ing the use of an analytic framework and consideration of study design s other than RCTs , the USPSTF could not conclude with even moderate certainty that the benefits of skin cancer screening by inspection outweighed the harms or that the harms outweighed the benefits , making the evidence insufficient to make a recommendation ( 9 ) . Even when non- RCT evidence is considered within a structured causal framework , the problem of insufficient evidence persists . A New Approach : Process and Outcome In response to the concerns about the frequency of I statements , the frustration expressed by clinicians , and the call for guidance , the USPSTF held a workshop in spring 2005 to consider how better to meet the needs of its constituents when evidence is insufficient . The workshop involved members of the USPSTF , AHRQ staff , and scientists from the Evidence -based Practice Center supporting the USPSTF . The charge to workshop participants was to develop a strategy that would reduce confusion created by the wording I recommendation , and to consider whether the USPSTF should nuance the Ithat is , make a suggestion in favor of or against providing the service . At the workshop , attendees heard presentations from AHRQ and Evidence -Based Practice Center staff involved in the efforts of the Grading of Recommendations , Assessment , Development , and Evaluation ( GRADE ) working group ( 1012 ) . Other publications about approaches to grading recommendations were identified and review ed ( 13 ) . The workshop result ed in a decision to transform what was formerly called an I recommendation into an I statement , as described elsewhere ( 2 ) . The workshop also led to a group decision to reject the proposal to nuance the I. Nuancing would have result ed in recommendations that clinicians act routinely to offer a service even in the absence of at least moderate certainty that the preventive service has net benefits at the population level , thus violating an underlying principle guiding the work of USPSTF : avoidance of overall harm . Before the workshop , attendees were charged with bringing to the meeting suggestions for criteria that might be used to nuance the I , with practice relevance for clinicians , patients , or systems as the basis for these suggestions . During the workshop , further criteria were identified by using a brainstorming technique . The product of these processes was a list of possible factors that could be used to nuance the I. After rejecting the idea of nuancing the I , the USPSTF decided to explore , after the workshop , whether provision of information about the factors identified during this process might be useful to clinicians . This follow-up work was delegated to the Methods Workgroup and members of the Evidence -based Practice Center . The follow-up group noted that almost all of the factors fell into 1 of 4 groups . The 4 information groups came to be described as domains , a term that connotes hierarchical ranking and is apt , even if accidental . That is , these information domains constitute a limited number of broadly applicable collection s of factors , considerations , or attributes pertinent to decision making about preventive services when evidence is insufficient to conclude , with certainty , that there is net benefit or net harm . After more deliberation , the Methods Workgroup proposed in 2006 that the Evidence -based Practice Center gather pertinent information in the 4 domains as part of its evidence retrieval process . The full USPSTF accepted the proposal , and members provided further input to the descriptions of the domains . The authors of this article were asked to prepare a manuscript about the process and product on behalf of the USPSTF . Domains and Rationale The first domain is potential preventable burden of suffering from the condition . When evidence is insufficient , provision of an intervention design ed to prevent a serious condition ( such as dementia ) might be viewed more favorably than provision of a service design ed to prevent a condition that does not cause as much suffering ( such as rash ) . The USPSTF recognized that burden of suffering is subjective and involves judgment . In clinical setting s , it should be informed by patient values and concerns . The second domain is potential harm of the intervention . When evidence is insufficient , an intervention with a large potential for harm ( such as major surgery ) might be viewed less favorably than an intervention with a small potential for harm ( such as advice to watch less television ) . The USPSTF again acknowledges the subjective nature and the difficulty of assessing potential harms : For example , how bad is a mild stroke ? The third domain is costnot just monetary cost , but opportunity cost , in particular the amount of time a provider spends to provide the Objective There is little r and omized controlled trial ( RCT ) evidence to guide treatment for anxiety after stroke . We systematic ally review ed RCTs of anxiety interventions in acquired brain injury ( ABI ) conditions including stroke and traumatic brain injury ( TBI ) in order to summarize efficacy and key aspects of trial design to help guide future RCTs . Methods We search ed the Cochrane trial register , Medline , Embase , PsychInfo and CINAHL systematic ally up to August 2017 . Two independent review ers systematic ally selected studies and extracted data . We summarized the effect size , key study characteristics and sources of potential bias in trial design . Results 14 studies ( 12 stroke ; one stroke & TBI ; one TBI ) with 928 participants were included . Meta- analysis of five psychotherapy comparisons favoured intervention over control ( st and ardized mean difference ( SMD ) : − 0.41 [ − 0.79 , − 0.03 ] , I2 = 28 % ) ; Overall effect size of pharmacotherapy comparisons favoured intervention over control ( SMD : − 2.12 [ − 3.05 , − 1.18 ] , I2 = 89 % ) . One comparison of mixed pharmacotherapy and psychotherapy favoured intervention over usual care ( SMD : − 4.79 [ − 5.87 , − 3.71 ] ) . One comparison favoured  forest therapy versus urban control ( SMD : − 2.00 [ − 2.59 , − 1.41 ] ) . All positive studies carried high or unclear risk of bias . Sample sizes were small in all included studies . Conclusions There is low quality evidence to suggest that psychotherapy and pharmacotherapy may be effective interventions in the treatment of anxiety after stroke based on underpowered studies that carried high risk of bias . Large-scale well- design ed definitive trials are needed to establish whether pharmacological or psychotherapy works . Our review highlighted key considerations for investigators wishing to design high quality trials to evaluate treatments for anxiety after stroke OBJECTIVE The purpose of the study was to determine the effect of six months of heavy resistance training ( weightlifting ) on the bone density of premenopausal women . EXPERIMENTAL DESIGN A 6-month prospect i ve design with r and om assignment to groups . SETTING Measurements of bone mineral density ( BMD ) were obtained from the Radiology Clinic at North Carolina Memorial Hospital . Exercise sessions were completed in the Physical Education Department facilities at the University of North Carolina , Chapel Hill , NC . PARTICIPANTS Thirty-five premenopausal women , 40 - 50 years of age , were r and omly assigned to either a resistance training ( RT ) and sedentary control ( CON ) group . The study finished with 12 women exercising and 14 in the control group . INTERVENTION The resistance training consisted of three days per week of high-intensity weightlifting specifically design ed to place strain on the spine and hips . MEASURES Bone density of the lumbar vertebrae , femoral neck , and distal radius , were determined prior to and at the end of the exercise program using dual energy X-ray absorptiometry ( DEXA ) . RESULTS Resistance-training produced strength gains : overhead press = 125 % , leg press = 86 % , and calf raises = 91 % ( p < 0.001 ) . RT tended to increased lumbar BMD 1.03 % , while the CON decreased 0.36 % ( p = 0.072 ) . Both groups lost radial BMD ( CON = -0.45 % ; RT = -1.04 % ) . Both groups gained femoral neck BMD ( CON = 1.26 % ; RT = 1.22 % ) . CONCLUSIONS These results suggest that even a short-term weight training program can either maintain or improve the BMD of the femoral neck and lumbar vertebrae in premenopausal women Patients with anorexia nervosa have concurrent problems of emaciation and depression . Therefore , treatment with medications affecting both weight gain and depression seemed reasonable . Seventy-two anorectic patients were r and omly assigned in a double-blind study to receive cyproheptadine hydrochloride , a weight-inducing drug , amitriptyline hydrochloride , a tricyclic antidepressant , or placebo . Overall , cyproheptadine had a marginal effect on decreasing the number of days necessary to achieve a normal weight . There was a differential drug effect present in the bulimic subgroups of the anorectic patients : cyproheptadine significantly increased treatment efficiency for the nonbulimic patients and significantly impaired treatment efficiency for the bulimic patients when compared with the amitriptyline- and placebo-treated groups . The differential cyproheptadine effect on the anorectic bulimic subgroups is the first pharmacologic evidence of the validity of these subgroups . Cyproheptadine had an anti-depressant effect demonstrated by a significant decrease in the Hamilton depression ratings These guidelines for the biological treatment of schizophrenia were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry ( WFSBP ) . The goal during the development of these guidelines was to review systematic ally all available evidence pertaining to the treatment of schizophrenia , and to reach a consensus on a series of practice recommendations that are clinical ly and scientifically meaningful based on the available evidence . These guidelines are intended for use by all physicians seeing and treating people with schizophrenia . The data used for developing these guidelines have been extracted primarily from various national treatment guidelines and panels for schizophrenia , as well as from meta-analyses , review s and r and omised clinical trials on the efficacy of pharmacological and other biological treatment interventions identified by a search of the MEDLINE data base and Cochrane Library . The identified literature was evaluated with respect to the strength of evidence for its efficacy and then categorised into four levels of evidence ( A – D ) . This first part of the guidelines covers disease definition , classification , epidemiology and course of schizophrenia , as well as the management of the acute phase treatment . These guidelines are primarily concerned with the biological treatment ( including antipsychotic medication , other pharmacological treatment options , electroconvulsive therapy , adjunctive and novel therapeutic strategies ) of adults suffering from schizophrenia
Cognitive behavioral therapy may reduce relapse risk for adults with AN after weight restoration , although its efficacy in the underweight state remains unknown .
Variants of family therapy are efficacious in adolescents , but not in adults .
Evidence for AN treatment is weak ; evidence for treatment-related harms and factors associated with efficacy of treatment are weak ; and evidence for differential outcome by sociodemographic factors is nonexistent .
OBJECTIVE The RTI International-University of North Carolina at Chapel Hill Evidence -based Practice Center ( RTI-UNC EPC ) systematic ally review ed evidence on efficacy of treatment for anorexia nervosa ( AN ) , harms associated with treatments , factors associated with treatment efficacy , and differential outcome by sociodemographic characteristics .