PMCC PMCC

Search tips
Search criteria

Advanced
Results 1-25 (679428)

Clipboard (0)
None

Related Articles

1.  Commentary: Progress and Challenges in Evidence-based Family Assessment in Pediatric Psychology 
Journal of Pediatric Psychology  2008;33(9):1062-1064.
It is widely accepted that families are integral to biopsychosocial, social ecological, and other systemic approaches for understanding families and pediatric health. Pediatric psychologists are among the strongest advocates for families. At the same time, families pose challenges that we (pediatric psychology as a field) struggle with in terms of theoretical conceptualizations, assessment and intervention approaches, and training. We primarily use individual frameworks in our practice and research. In this brief commentary, prompted by the report of accomplishments in evidence-based family assessment in pediatric psychology (Alderfer et al., 2007), I outline some of the background for an implicit “challenge” to our field to advance our family orientation and provide some concrete ideas about next steps.
doi:10.1093/jpepsy/jsn061
PMCID: PMC2639488
2.  Foot Orthoses in Lower Limb Overuse Conditions: A Systematic Review and Meta-Analysis—Critical Appraisal and Commentary 
Journal of Athletic Training  2011;46(1):103-106.
Abstract
Reference/Citation:
Collins N, Bisset L, McPoil T, Vicenzino B. Foot orthoses in lower limb overuse conditions: a systematic review and meta-analysis. Foot Ankle Int. 2007;28(3):396–412.
Clinical Question:
Among patients with or at risk for musculoskeletal overuse conditions, (1) do foot orthoses provide clinically meaningful improvements, and (2) are foot orthoses cost-effective?
Data Sources:
Studies published through September 28, 2005, were identified by using MEDLINE, EMBASE, CINAHL and Pre-CINAHL, Physiotherapy Evidence Database (PEDro), PubMed, SPORTDiscus, Biological Abstracts, Web of Science, Allied Health and Complementary Medicine Database, and the full Cochrane Library. The authors did not provide the search strategy used. Reference lists of included randomized controlled trials (RCTs) and identified systematic reviews were searched by hand.
Study Selection:
Studies were included if (1) they were RCTs that included the use of foot orthoses (either custom or prefabricated) in 1 of the intervention groups, (2) the clinical problem was an overuse condition as defined by the American College of Foot and Ankle Orthopedics and Medicine guidelines for which foot orthoses were recommended, and (3) at least 1 clinically relevant outcome was measured for a minimum of 1 week. Limits were not placed on year of publication, status of publication, or language.
Data Extraction:
The journal, authors, and author affiliations of included RCTs were masked from 2 of the reviewers who independently assessed the included RCTs for methodologic quality using a modified PEDro scale plus 3 additional items (justification of sample size, use of outcome measures with known validity and reliability, and reporting of adverse or side effects). Disagreements on methodologic quality were resolved with consensus or by a third reviewer. The effect sizes for the included RCTs were represented by relative risk (RR) for dichotomous outcomes and standardized mean difference (SMD) for continuous data. Confidence intervals (CIs) were reported for RR and SMD. Study data were extracted directly from each of the included studies. If provided, data from intention-to-treat analysis were extracted. Study authors were contacted when insufficient data were reported. A meta-analysis (random-effects model) was conducted using Review Manager (version 4.2; The Nordic Cochrane Centre, Copenhagen, Denmark).
Main Results:
The search identified 3192 potentially relevant studies. Full articles were retrieved for 327 studies. Twenty-two of the 327 studies met the inclusion criteria. Because the authors of 1 study used the same methods to report on 2 populations, a total of 23 RCTs were included in the systematic review. Prevention of lower limb overuse conditions with the use of foot orthoses was reported in 8 RCTs (7 studies). The effect of foot orthoses in the treatment of lower limb overuse conditions was reported in 15 RCTs. Of the 23 RCTs, the cost-effectiveness of foot orthoses was reported in 2 and the adverse effects of foot orthoses were reported in 8. Across the prevention RCTs, data were available for analysis for a range of 47 to 417 participants with 8 to 16 weeks of follow-up. Based on 4 RCTs in which the researchers examined prevention of lower limb overuse conditions with foot orthoses versus control in military personnel, the RR was 1.49 (95% CI  =  1.07, 2.08). A clinically beneficial effect size was set a priori at 1.5 or greater for the foot-orthoses group or at 0.7 or less for the comparison group. Based on 2 RCTs reported in 1 study of the use of custom versus prefabricated foot orthoses for prevention of lower limb overuse conditions, no significant difference in risk was found (RR  =  1.14, 95% CI  =  0.90, 1.44). In their calculating and reporting of RR, the authors do not appear to have followed convention. Across the treatment RCTs, data were available for analysis for a range of 18 to 133 participants with 8 to 52 weeks of follow-up. The authors of the treatment RCTs reported a variety of outcome measures. Two of these, patient-perceived treatment effect (PPE) and pain on the visual analog scale (VAS), were used to calculate an overall treatment effect (PPE as RR and VAS as SMD). Based on 2 RCTs examining foot orthoses versus control, no significant difference in PPE was found (RR  =  1.01, 95% CI  =  0.61, 1.68). Based on 2 RCTs in which custom versus prefabricated foot orthoses were examined, no significant difference in PPE was found (RR  =  0.88, 95% CI  =  0.42, 1.81). The VAS data reported in the text appear to contradict the VAS data reported in Figure 2 for foot orthoses versus control for the treatment of lower limb overuse conditions. Specifically, the lower limit of the CI in the text was negative (−0.28) and in Figure 2 was positive. Because of this apparent contradiction, we did not interpret these data. Authors of 2 RCTs reported cost-effectiveness, but the data could not be pooled. Adverse events were reported in 8 of the 22 studies. The most common adverse effect reported was discomfort, which was the main reason for discontinuing foot-orthoses use in 2 studies.
Conclusions:
The evidence supports the use of foot orthoses to prevent a first occurrence of lower limb overuse conditions and shows no difference between custom and prefabricated foot orthoses. The evidence was insufficient to recommend foot orthoses (custom or prefabricated) for the treatment of lower limb overuse conditions.
doi:10.4085/1062-6050-46.1.103
PMCID: PMC3017481  PMID: 21214358
overuse injuries; foot orthotics
3.  Efficacy and safety of duloxetine 60 mg once daily in major depressive disorder: a review with expert commentary 
Drugs in Context  2013;2013:212245.
Objective:
Major depressive disorder (MDD) is a significant public health concern and challenges health care providers to intervene with appropriate treatment. This article provides an overview of efficacy and safety information for duloxetine 60 mg/day in the treatment of MDD, including its effect on painful physical symptoms (PPS).
Design:
A literature search was conducted for articles and pooled analyses reporting information regarding the use of duloxetine 60 mg/day in placebo-controlled trials.
Setting:
Placebo-controlled, active-comparator, short- and long-term studies were reviewed.
Participants:
Adult (≥18 years) patients with MDD.
Measurements:
Effect sizes for continuous outcome (change from baseline to endpoint) and categorical outcome (response and remission rates) were calculated using the primary measures of 17-item Hamilton Rating Scale for Depression (HAMD-17) or Montgomery–Åsberg Depression Rating Scale (MADRS) total score. The Brief Pain Inventory and Visual Analogue Scales were used to assess improvements in PPS. Glass estimation method was used to calculate effect sizes, and numbers needed to treat (NNT) were calculated based on HAMD-17 and MADRS total scores for remission and response rates. Safety data were examined via the incidence of treatment-emergent adverse events and by mean changes in vital-sign measures.
Results:
Treatment with duloxetine was associated with small-to-moderate effect sizes in the range of 0.12 to 0.72 for response rate and 0.07 to 0.65 for remission rate. NNTs were in the range of 3 to 16 for response and 3 to 29 for remission. Statistically significant improvements (p≤0.05) were observed in duloxetine-treated patients compared to placebo-treated patients in PPS and quality of life. The safety profile of the 60-mg dose was consistent with duloxetine labeling, with the most commonly observed significant adverse events being nausea, dry mouth, diarrhea, dizziness, constipation, fatigue, and decreased appetite.
Conclusion:
These results reinforce the efficacy and tolerability of duloxetine 60 mg/day as an effective short- and long-term treatment for adults with MDD. The evidence of the independent analgesic effect of duloxetine 60 mg/day supports its use as a treatment for patients with PPS associated with depression. This review is limited by the fact that it included randomized clinical trials with different study designs. Furthermore, data from randomized controlled trials may not generalize well to real clinical practice.
doi:10.7573/dic.212245
PMCID: PMC3884746  PMID: 24432034
duloxetine; major depressive disorder; painful physical symptoms; quality of life; effect size; safety and tolerability
4.  Mechanism-based Classification of Pain for Physical Therapy Management in Palliative care: A Clinical Commentary 
Pain relief is a major goal for palliative care in India so much that most palliative care interventions necessarily begin first with pain relief. Physical therapists play an important role in palliative care and they are regarded as highly proficient members of a multidisciplinary healthcare team towards management of chronic pain. Pain necessarily involves three different levels of classification–based upon pain symptoms, pain mechanisms and pain syndromes. Mechanism-based treatments are most likely to succeed compared to symptomatic treatments or diagnosis-based treatments. The objective of this clinical commentary is to update the physical therapists working in palliative care, on the mechanism-based classification of pain and its interpretation, with available therapeutic evidence for providing optimal patient care using physical therapy. The paper describes the evolution of mechanism-based classification of pain, the five mechanisms (central sensitization, peripheral neuropathic, nociceptive, sympathetically maintained pain and cognitive-affective) are explained with recent evidence for physical therapy treatments for each of the mechanisms.
doi:10.4103/0973-1075.78458
PMCID: PMC3098553  PMID: 21633629
Mechanism-based classification; Pain rehabilitation; Pain sciences; Palliative physical therapy care
5.  Commentary – ordering lab tests for suspected rheumatic disease 
One of the least-appreciated advances in pediatric rheumatology over the past 25 years has been the delineation of the many ways in which children with rheumatic disease differ from adults with the same illnesses. Furthermore, we are now learning that paradigms that are useful in evaluating adults with musculoskeletal complaints have limited utility in children. Nowhere is that more true than in the use of commonly used laboratory tests, particularly antinuclear antibody (ANA) and rheumatoid factor (RF) assays. This short review will provide the practitioner with the evidence base that supports a more limited use of ANA and RF testing in children.
doi:10.1186/1546-0096-6-19
PMCID: PMC2588570  PMID: 19014701
6.  Commentary: we can tell where it hurts, but can we tell where the pain is coming from or where we should manipulate? 
The shared decision making process has become increasingly important in the management of spinal disorders where there remains a variety of treatment options. Spinal manipulative therapy (SMT) is often recommended as a conservative option by evidence based clinical practice guidelines and a treatment modality frequently utilized by chiropractors and other clinicians who offer SMT to their patients. This article serves as a commentary to a review of the methods that are often used by chiropractors to determine the site for applying their manipulative intervention. Though it may be easy to criticize any review of this type of literature and point out shortcomings there are strong take away messages for the clinician interested in employing SMT as a part of their treatment protocol. Most notably, clinicians can be reassured that a history on the localization of pain, tissue palpation, provocative testing, range of motion testing and the demonstration by the patient of the locus and description of pain have reasonable consistency between observers. What this paper does not inform us on is the nature of the lesion causing the pain or where the manipulation should be applied to obtain the best outcome.
doi:10.1186/2045-709X-21-35
PMCID: PMC4029163  PMID: 24499590
Chiropractic; Spinal manipulative therapy; Spine palpation; Clinical decision making
7.  The need to reform our assessment of evidence from clinical trials: A commentary 
The ideology of evidence-base medicine (EBM) has dramatically altered the way we think, conceptualize, philosophize and practice medicine. One of its major pillars is the appraisal and classification of evidence. Although important and beneficial, this process currently lacks detail and is in need of reform. In particular, it largely focuses on three key dimensions (design, [type I] alpha error and beta [type II] error) to grade the quality of evidence and often omits other crucial aspects of evidence such as biological plausibility, reproducibility, generalizability, temporality, consistency and coherence. It also over-values the randomized trial and meta-analytical techniques, discounts the biasing effect of single centre execution and gives insufficient weight to large and detailed observational studies. Unless these aspects are progressively included into systems for grading, evaluating and classifying evidence and duly empirically assessed (according to the EBM paradigm), the EBM process and movement will remain open to criticism of being more evidence-biased than evidence-based.
"All scientific work is incomplete – whether it be observational or experimental. All scientific work is liable to be upset or modified by advancing knowledge. That does not confer upon us a freedom to ignore the knowledge we already have, or to postpone the action that it appears to demand at a given time".
Sir Bradford Austin Hill [1]
doi:10.1186/1747-5341-3-23
PMCID: PMC2569956  PMID: 18826605
8.  A review of, and commentary on, the ongoing second clinical introduction of preimplantation genetic screening (PGS) to routine IVF practice 
Purpose
Current re-introduction of “improved” preimplantation genetic screening (PGS#2) raises the question whether PGS#2 is ready for routine clinical application.
Methods
We assessed available evidence via review of published data for years 2005–2012, and review of currently ongoing registered clinical trials, based on searches under appropriate key words in PubMed, MEDLINE, Cochrane Database System Review and Google Scholar and http://www.ClinicalTrials.gov. In absence of prospective clinical trials, and due to limited available data, individual publications/ongoing studies are assessed.
Results
PGS#2 offers significant improvements in accuracy of aneuploidy diagnosis over PGS#1. By moving embryo biopsy from day-3 after fertilization (6–8 cell stage) to trophectoderm biopsy at blastocyst stage (day 5–6), PGS#2, however, adds additional co-variables to the analysis of efficacy of the procedure, which have special relevance for women with diminished ovarian reserve (DOR), who usually produce small egg and embryo numbers. Limited published data, claiming efficacy of PGS#2, as well as ongoing clinical trials, do not consider these additional co-variables, do not analyze outcomes by intent to treat and, therefore, have to be considered biased in patient selection.
Conclusions
Here reached conclusions are based on absence of adequate data rather than affirmative outcome assessments. They, therefore, are subject to change at any future date with generation of significant new data. Premature introduction of PGS#1 caused significant damage to patients. As currently no reliable PGS#2 data are available to suggest improvements in IVF outcomes, to avoid a repeat of the PGS#1 experience, PGS#2 should be considered experimental until data show otherwise.
doi:10.1007/s10815-012-9871-2
PMCID: PMC3510363  PMID: 23054362
In vitro fertilization (IVF); Preimplantation genetic screening (PGS); Aneuploidy; FISH; Array techniques; Embryo biopsy; Experimental procedure
9.  Commentary on Using LNT for Radiation Protection and Risk Assessment 
Dose-Response  2010;8(3):378-383.
An article by Jerome Puskin attempts to justify the continued use of the linear no-threshold (LNT) assumption in radiation protection and risk assessment. In view of the substantial and increasing amount of data that contradicts this assumption; it is difficult to understand the reason for endorsing this unscientific behavior, which severely constrains nuclear energy projects and the use of CT scans in medicine. Many Japanese studies over the past 25 years have shown that low doses and low dose rates of radiation improve health in living organisms including humans. Recent studies on fruit flies have demonstrated that the original basis for the LNT notion is invalid. The Puskin article omits any mention of important reports from UNSCEAR, the NCRP and the French Academies of Science and Medicine, while citing an assessment of the Canadian breast cancer study that manipulated the data to obscure evidence of reduced breast cancer mortality following a low total dose. This commentary provides dose limits that are based on real human data, for both single and chronic radiation exposures.
doi:10.2203/dose-response.10-003.Cuttler
PMCID: PMC2939692  PMID: 20877492
10.  Quality in the provision of headache care. 1: systematic review of the literature and commentary 
The Journal of Headache and Pain  2012;13(6):437-447.
Widely accepted quality indicators for headache care would provide a basis not only for assessment of care but also, and more importantly, for its improvement. The objective of the study was to identify and summarize existing information on such indicators: specifically, did indicators exist, how had they been developed, what aspects of headache care did they relate to and how and with what utility were they being used? A systematic review of the medical literature was performed. A total of 32 articles met criteria for inclusion. We identified 55 existing headache quality indicators of which 37 evaluated processes of headache care. Most were relevant only to specific populations of patients and to care delivered in high-resource settings. Indicators had been used to describe overall quality of headache care at a national level, but not systematically applied to the evaluation and improvement of headache services in other settings. Some studies had evaluated the use of existing disability and quality of life instruments, but their findings had not been incorporated into quality indicators. Existing headache care quality indicators are incomplete and inadequate for purpose. They emphasize processes of care rather than structure or outcomes, and are not widely applicable to different levels and locations of headache care. Furthermore, they do not fully incorporate accepted evidence regarding optimal methods of care. There is a clear need for consensus-based indicators that fully reflect patients’ and public-health priorities. Ideally, these will be valid across cultures and health-care settings.
Electronic supplementary material
The online version of this article (doi:10.1007/s10194-012-0466-1) contains supplementary material, which is available to authorized users.
doi:10.1007/s10194-012-0466-1
PMCID: PMC3464474  PMID: 22736100
Headache; Quality of care; Quality indicators; Systematic review; Global Campaign against Headache
11.  Commentary: Pediatric Obesity: Systems Science Strategies for Prevention 
Journal of Pediatric Psychology  2013;38(9):1044-1050.
Objectives Pediatric obesity is a major public health problem that undermines the physical and mental health of children and increases their risk for adult obesity and other chronic illnesses. Although health care providers, including pediatric psychologists, have implemented prevention programs, effects have been minimal, with no solid evidence of sustainable programs. Methods A systems science framework that incorporates the multiple interacting factors that influence pediatric obesity may be useful in guiding prevention. Results The National Prevention Strategy provides recommendations that can be incorporated into systems science designs, including (1) Healthy and Safe Environments, (2) Clinical and Community Preventive Services, (3) Empowering People, and (4) Elimination of Health Disparities. In addition, our recommendation is that future obesity prevention programs target early in life (pre-pregnancy through toddlerhood) and use multilevel multidisciplinary designs. Conclusions The benefits of preventing pediatric obesity extend from the health and well-being of individual children to the economic security of the nation.
doi:10.1093/jpepsy/jst071
PMCID: PMC3888301  PMID: 24013965
12.  Drugs for chronic pain in children: A commentary on clinical practice and the absence of evidence 
Pediatric chronic pain is widespread, under-recognized and undertreated. Best management usually involves a multimodal approach coordinated by a multidisciplinary team. The present commentary specifically discusses common pharmacological approaches to chronic pain in children, identifies gaps in knowledge and suggests several research directions that would benefit future clinical care.
PMCID: PMC3665437  PMID: 23457686
Adolescent; Child; Chronic pain; Drug treatment
13.  Pain Mechanisms: A Commentary on Concepts and Issues 
Progress in neurobiology  2011;94(1):20-38.
This commentary on ideas about neural mechanisms underlying pain is aimed at providing perspective for a reader who does not work in the field of mammalian somatic sensation. It is not a comprehensive review of the literature. The organization is historical to chronicle the evolution of ideas. The aim is to call attention to source of concepts and how various ideas have fared over time.
One difficulty in relating concepts about pain is that the term is used to refer to human and animal reactions ranging from protective spinal reflexes to complex affective behaviors. As a result, the spectrum of “pain”-related neural organization extends to operation of multiple neuronal arrangements.
Thinking about pain has shadowed progress in understanding biological mechanisms, in particular the manner of function of nervous systems. This essay concentrates on the evolution of information and concepts from the early 19th century to the present. Topics include the assumptions underlying currently active theories about pain mechanisms. At the end, brief consideration is given to present-day issues, e.g., chronic pain, central pain, and the view of pain as an emotion rather than a sensation. The conceptual progression shows that current controversies have old roots and that failed percepts often resurface after seemingly having been put to rest by argument and evidence.
doi:10.1016/j.pneurobio.2011.03.001
PMCID: PMC3138063  PMID: 21419824
14.  Joint Manipulation in the Management of Lateral Epicondylalgia: A Clinical Commentary 
Lateral epicondylalgia or tennis elbow is a prevalent musculoskeletal disorder that is characterized by lateral elbow pain often associated with gripping tasks. The underlying pathology remains to be fully elucidated; however, evidence indicates that the disorder does not involve an inflammatory process but rather impairments of the pain and motor systems as well as morphological changes in the structure of both the extensor carpi radialis brevis muscle and tendon. Although the most efficient management approach remains controversial, there is a growing body of literature reporting the effects and underlying mechanisms of joint manipulation in the management of lateral epicondylalgia. Evidence exists demonstrating that joint manipulation directed at the elbow and wrist as well as at the cervical and thoracic spinal regions results in clinical alterations in pain and the motor system. In addition to presenting this evidence, this paper describes proposed underlying physiological mechanisms of joint manipulation associated with the observed clinical effects. We propose that this information will be useful for the physical therapist in making clinical decisions regarding the selection of treatment technique for the management of patients with lateral epicondylalgia.
PMCID: PMC2565595  PMID: 19066643
Tennis Elbow; Joint Mobilization; Joint Manipulation; Manual Therapy
15.  Spinal manipulation under anesthesia: a narrative review of the literature and commentary 
As exhibited throughout the medical literature over many decades, there is a lack of uniformity in the manner in which spine pain patients have historically qualified for and received manipulation under anesthesia (MUA). Also, for different professions that treat the same types of spinal conditions via the same means, fundamental MUA decision points vary within the published protocols of different professional associations. The more recent chiropractic literature communicates that the evidence to support the efficacy of MUA of the spine remains largely anecdotal. In addition, it has been reported that the types of spinal conditions most suitable for MUA are without clear-cut consensus, with various indications for MUA of the low back resting wholly upon the opinions and experiences of MUA practitioners. This article will provide a narrative review of the MUA literature, followed by a commentary about the current lack of high quality research evidence, the anecdotal and consensus basis of existing clinical protocols, as well as related professional, ethical and legal concerns for the chiropractic practitioner. The limitations of the current medical literature related to MUA via conscious/deep sedation need to be recognized and used as a guide to clinical experience when giving consideration to this procedure. More research, in the form of controlled clinical trials, must be undertaken if this procedure is to remain a potential treatment option for chronic spine pain patients in the chiropractic clinical practice.
doi:10.1186/2045-709X-21-14
PMCID: PMC3691523  PMID: 23672974
Manipulation under anesthesia; Spine; Efficacy; Medical evidence; Quality; Ethics
16.  Evidence-based medicine: a commentary on common criticisms 
Discussions about evidence-based medicine engender both negative and positive reactions from clinicians and academics. Ways to achieve evidence-based practice are reviewed here and the most common criticisms described. The latter can be classified as ”limitations universal to the practice of medicine,” ”limitations unique to evidence-based medicine” and ”misperceptions of evidence-based medicine.” Potential solutions to the true limitations of evidence-based medicine are discussed and areas for future work highlighted.
PMCID: PMC80509  PMID: 11033714
17.  Invited Commentary: Broadening the Evidence for Adolescent Sexual and Reproductive Health and Education in the United States 
Journal of Youth and Adolescence  2014;43(10):1595-1610.
Scientific research has made major contributions to adolescent health by providing insights into factors that influence it and by defining ways to improve it. However, US adolescent sexual and reproductive health policies—particularly sexuality health education policies and programs—have not benefited from the full scope of scientific understanding. From 1998 to 2009, federal funding for sexuality education focused almost exclusively on ineffective and scientifically inaccurate abstinence-only-until-marriage (AOUM) programs. Since 2010, the largest source of federal funding for sexual health education has been the “tier 1” funding of the Office of Adolescent Health’s Teen Pregnancy Prevention Initiative. To be eligible for such funds, public and private entities must choose from a list of 35 programs that have been designated as “evidence-based” interventions (EBIs), determined based on their effectiveness at preventing teen pregnancies, reducing sexually transmitted infections, or reducing rates of sexual risk behaviors (i.e., sexual activity, contraceptive use, or number of partners). Although the transition from primarily AOUM to EBI is important progress, this definition of evidence is narrow and ignores factors known to play key roles in adolescent sexual and reproductive health. Important bodies of evidence are not treated as part of the essential evidence base, including research on lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ) youth; gender; and economic inequalities and health. These bodies of evidence underscore the need for sexual health education to approach adolescent sexuality holistically, to be inclusive of all youth, and to address and mitigate the impact of structural inequities. We provide recommendations to improve US sexual health education and to strengthen the translation of science into programs and policy.
doi:10.1007/s10964-014-0178-8
PMCID: PMC4162986  PMID: 25200033
18.  Which antidepressant? A commentary from general practice on evidence-based medicine and health economics. 
BACKGROUND: With increasing demand for health care, evidence-based medicine combined with health economics offers a method of optimizing allocation of limited resources. Depression is an illness that has a high prevalence with important medical, social and economic implications. More than 90% of depression is diagnosed and treated in general practice. AIM: To review the effectiveness of an evidence-based approach combined with health economics in deciding whether a tricyclic antidepressant (TCA) or a selective serotonin reuptake inhibitor (SSRI) should be used in the treatment of depression in general practice. METHOD: An evidence-based strategy tested the two treatments against the criteria of appropriateness, efficacy, effectiveness and value for money. RESULTS: Although both drugs were equally efficacious, their relative effectiveness and value for money could not be accurately defined. CONCLUSION: An evidence-based approach does not make clear whether SSRIs or TCAs should be used for the treatment of depression in general practice. Research questions arising from general practice should be addressed in a relevant setting and should yield answers that will complement and support a more pragmatic system of medicine rather than seek to direct it.
PMCID: PMC1312914  PMID: 9101693
19.  COMMENTARY ON THE COCHRANE REVIEW OF ACUPUNCTURE AND ASSISTED CONCEPTION 
Explore (New York, N.Y.)  2011;7(2):120-123.
Background
Acupuncture has recently been studied in assisted reproductive treatment (ART) although its role in reproductive medicine is still debated.
Objectives
To determine the effectiveness of acupuncture in the outcomes of ART.
Search strategy
All reports which describe randomised controlled trials of acupuncture in assisted conception were obtained through searches of the Menstrual Disorders and Subfertility Group Specialised Register, CENTRAL, Ovid MEDLINE (1996 to August 2007), EMBASE (1980 to August 2007), CINAHL (Cumulative Index to Nursing & Allied Health Literature) (1982 to August 2007), AMED, National Research Register, Clinical Trials register (www.clinicaltrials.gov), and the Chinese database of clinical trials.
Selection Criteria
Randomised controlled trials of acupuncture for couples who were undergoing ART comparing acupuncture treatment alone or acupuncture with concurrent ART versus no treatment, placebo or sham acupuncture plus ART for the treatment of primary and secondary infertility. Women with medical illness deemed contraindications for ART or acupuncture were excluded.
Data Collection and Analysis
Sixteen randomised controlled trials were identified that involved acupuncture and assisted conception. Thirteen trials were included in the review and three were excluded. Quality assessment and data extraction were performed independently by two review authors.
Meta-analysis was performed using odds ratio (OR) for dichotomous outcomes. The outcome measures were live birth rate, clinical ongoing pregnancy rate, miscarriage rate, and any reported side effects of treatment.
Main Results
There is evidence of benefit when acupuncture is performed on the day of embryo transfer (ET) on the live birth rate (OR 1.89, 95% CI 1.29 to 2.77) but not when it is performed two to three days after ET (OR 1.79, 95% CI 0.93 to 3.44). There is no evidence of benefit on pregnancy outcomes when acupuncture is performed around the time of oocyte retrieval.
Authors’ Conclusions
Acupuncture performed on the day of ET shows a beneficial effect on the live birth rate; however, with the present evidence this could be attributed to placebo effect and the small number of women included in the trials. Acupuncture should not be offered during the luteal phase in routine clinical practice until further evidence is available from sufficiently powered RCTs.
doi:10.1016/j.explore.2010.12.016
PMCID: PMC3086273  PMID: 21397874
20.  Indian commentary on the 2009 KDIGO clinical practice guideline for the diagnosis, evaluation, and treatment of chronic kidney disease-mineral and bone disorders 
Indian Journal of Nephrology  2011;21(3):143-151.
This commentary presents the view of an Expert Group of Indian nephrologists on adaptation and implementation of the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines for evaluation and management of mineral and bone disorder in chronic kidney disease (CKD-MBD) for practice in India. Zonal meetings of nephrologists drawn from the cross-section were convened to discuss the KDIGO guidelines. Recommendations were presented in a central meeting of zonal representatives. The finalized recommendations were reviewed by all the participants. There was a broad agreement on most of the recommendations made by the KDIGO workgroup. Significant departures in the current guidelines from the previous Kidney Disease Outcome Quality Initiative (KDOQI) guidelines were also noted. The participants agreed that the available evidence did not allow more precise recommendations, and the recommended best practice suggestions were often based on relatively weak evidence. There is a remarkable lack of data from Indian patients. We comment on specific areas and amplify certain concepts where we feel that further guidance that goes beyond what is stated in the document might help Indian nephrologists in appropriate implementation of the KDIGO guidelines. This commentary is intended to help define practically implementable best practices based on current disease concepts and available research evidence, thereby positively affecting the quality of management of CKD-MBD in India, and eventually improving patient outcomes.
doi:10.4103/0971-4065.83930
PMCID: PMC3161429  PMID: 21886971
Chronic kidney disease; guideline; hyperparathyroidism; KDIGO; mineral and bone disorder
21.  Commentary: Eight Ways to Prevent Cancer: a framework for effective prevention messages for the public 
Cancer causes & control : CCC  2012;23(4):601-608.
Research over the past 40 years has convincingly shown that lifestyle factors play a huge role in cancer incidence and mortality. The public, though, can often discount the preventability of cancer. That health information on the Internet is a vast and often scientifically suspect commodity makes promoting important and sound cancer prevention messages to the pubic even more difficult. To help address these issues and improve the public’s knowledge of, and attitudes toward, cancer prevention, there need to be concerted efforts to create evidence-based, user-friendly information about behaviors that could greatly reduce overall cancer risk. Toward this end, we condensed the current scientific evidence on the topic into eight key behaviors. While not an end in themselves, “8 Ways to Stay Healthy and Prevent Cancer” forms an evidence-based and targeted framework that supports broader cancer prevention efforts.
doi:10.1007/s10552-012-9924-y
PMCID: PMC3685578  PMID: 22367724
Cancer prevention; risk factors; lifestyle modification; health communication; policy
22.  KDOQI US Commentary on the 2012 KDIGO Clinical Practice Guideline for Management of Blood Pressure in CKD 
In response to the 2012 KDIGO (Kidney Disease: Improving Global Outcomes) guideline for blood pressure management in patients with chronic kidney disease not on dialysis, the National Kidney Foundation organized a group of US experts in hypertension and transplant nephrology to review the recommendations and comment on their relevancy in the context of current US clinical practice and concerns. The overriding message was the dearth of clinical trial evidence to provide strong evidence-based recommendations. For patients with CKD with normal to mildly increased albuminuria, goal blood pressure has been relaxed to ≤140/90 mm Hg for both diabetic and nondiabetic patients. In contrast, KDIGO continues to recommend goal blood pressure ≤130/80 mm Hg for patients with chronic kidney disease with moderately or severely increased albuminuria and for all renal transplant recipients regardless of the presence of proteinuria, without supporting data. The expert panel thought the KDIGO recommendations were generally reasonable but lacking in sufficient evidence support and that additional studies are greatly needed.
doi:10.1053/j.ajkd.2013.03.018
PMCID: PMC3929429  PMID: 23684145
Kidney Disease: Improving Global Outcomes (KDIGO); guideline; blood pressure
23.  Soy isoflavones, estrogen therapy, and breast cancer risk: analysis and commentary 
Nutrition Journal  2008;7:17.
There has been considerable investigation of the potential for soyfoods to reduce risk of cancer, and in particular cancer of the breast. Most interest in this relationship is because soyfoods are essentially a unique dietary source of isoflavones, compounds which bind to estrogen receptors and exhibit weak estrogen-like effects under certain experimental conditions. In recent years the relationship between soyfoods and breast cancer has become controversial because of concerns – based mostly on in vitro and rodent data – that isoflavones may stimulate the growth of existing estrogen-sensitive breast tumors. This controversy carries considerable public health significance because of the increasing popularity of soyfoods and the commercial availability of isoflavone supplements. In this analysis and commentary we attempt to outline current concerns regarding the estrogen-like effects of isoflavones in the breast focusing primarily on the clinical trial data and place these concerns in the context of recent evidence regarding estrogen therapy use in postmenopausal women. Overall, there is little clinical evidence to suggest that isoflavones will increase breast cancer risk in healthy women or worsen the prognosis of breast cancer patients. Although relatively limited research has been conducted, and the clinical trials often involved small numbers of subjects, there is no evidence that isoflavone intake increases breast tissue density in pre- or postmenopausal women or increases breast cell proliferation in postmenopausal women with or without a history of breast cancer. The epidemiologic data are generally consistent with the clinical data, showing no indication of increased risk. Furthermore, these clinical and epidemiologic data are consistent with what appears to be a low overall breast cancer risk associated with pharmacologic unopposed estrogen exposure in postmenopausal women. While more research is required to definitively allay concerns, the existing data should provide some degree of assurance that isoflavone exposure at levels consistent with historical Asian soyfood intake does not result in adverse stimulatory effects on breast tissue.
doi:10.1186/1475-2891-7-17
PMCID: PMC2443803  PMID: 18522734
24.  Invited Commentary: Assessing Treatment Effects by Using Observational Analyses—Opportunities and Limitations 
American Journal of Epidemiology  2009;170(3):286-287.
Making decisions about medical treatments based upon valid evidence is critical to improve health-care quality, outcomes, and value. Although such research commonly connotes the use of randomized controlled trials, experimental methods are not always feasible, and research using observational, quasi-experimental, and other nonexperimental methods may also be important. At the same time, nonexperimental methods are inherently susceptible to various types of bias and thus present special challenges in the search for valid and generalizable evidence. The study by Gardarsdottir et al. (Am J Epidemiol. 2009;170(3):280–285), on which this commentary is based, addresses a key potential source of bias—mismeasurement of patients’ duration of treatment—in previous research on pharmacotherapy for depression. However, the authors’ study is unlikely to address other potential sources of bias, which may make interpretation of their findings more difficult.
doi:10.1093/aje/kwp137
PMCID: PMC2727173  PMID: 19498072
bias (epidemiology); depression; observation; research design; treatment outcome
25.  What Patients Value When Oncologists Give News of Cancer Recurrence: Commentary on Specific Moments in Audio-Recorded Conversations 
The Oncologist  2011;16(3):342-350.
This study was designed to understand patient perspectives on what patients value when oncologists communicate news of cancer recurrence. This study adds to the empirical evidence base about how oncologists should discuss news of cancer recurrence and identifies recognition, guidance, and responsiveness as patient-centered qualities of communication in this situation.
Learning Objectives
After completing this course, the reader will be able to: Incorporate the three themes identified in this study to refine discussion with patients of their cancer recurrence.Manage discussion with patients of cancer recurrence with recognition of the impact of the news on the patient and guidance as to next steps.
This article is available for continuing medical education credit at CME.TheOncologist.com
Purpose.
Recommendations for communicating bad or serious news are based on limited evidence. This study was designed to understand patient perspectives on what patients value when oncologists communicate news of cancer recurrence.
Study Design and Methods.
Participants were 23 patients treated for a gastrointestinal cancer at a tertiary U.S. cancer center within the past 2 years, who had semistructured qualitative interviews in which they listened to audio recordings of an oncology fellow discussing news of cancer recurrence with a standardized patient. Participants paused the audio recording to comment on what they liked or disliked about the oncologist's communication.
Results.
Three themes were identified that refine existing approaches to discussing serious news. The first theme, recognition, described how the oncologist responded to the gravity of the news of cancer recurrence for the patient. Participants saw the need for recognition throughout the encounter and not just after the news was given. The second theme, guiding, describes what participants wanted after hearing the news, which was for the oncologist to draw on her biomedical expertise to frame the news and plan next steps. The third theme, responsiveness, referred to the oncologist's ability to sense the need for recognition or guidance and to move fluidly between them.
Conclusion.
This study suggests that oncologists giving news of cancer recurrence could think of the communication as going back and forth between recognition and guidance and could ask themselves: “Have I demonstrated that I recognize the patient's experience hearing the news?” and “Have I provided guidance to the next steps?”
doi:10.1634/theoncologist.2010-0274
PMCID: PMC3228111  PMID: 21349951
Communication; Medical ethics; Information-seeking behavior; Palliative care

Results 1-25 (679428)