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.
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.
Mechanism-based classification; Pain rehabilitation; Pain sciences; Palliative physical therapy care
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.
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 
Current re-introduction of “improved” preimplantation genetic screening (PGS#2) raises the question whether PGS#2 is ready for routine clinical application.
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.
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.
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.
In vitro fertilization (IVF); Preimplantation genetic screening (PGS); Aneuploidy; FISH; Array techniques; Embryo biopsy; Experimental procedure
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.
Adolescent; Child; Chronic pain; Drug treatment
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.
Tennis Elbow; Joint Mobilization; Joint Manipulation; Manual Therapy
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.
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.
Manipulation under anesthesia; Spine; Efficacy; Medical evidence; Quality; Ethics
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.
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.
Cancer prevention; risk factors; lifestyle modification; health communication; policy
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.
bias (epidemiology); depression; observation; research design; treatment outcome
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.
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
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.
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.
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?”
Communication; Medical ethics; Information-seeking behavior; Palliative care
Arsenic exposure affects millions of people worldwide, causing substantial mortality and morbidity from cancers and cardiovascular and respiratory diseases. An article in the current issue (Am J Epidemiol. 2013;177(3):202–212) reports that classic dermatological manifestations, typically associated with chronic arsenic exposure, are predictive of internal cancers among Taiwanese decades after the cessation of exposure. Specifically, the risk of lung and urothelial cancers was elevated, which was evident regardless of arsenic dose, smoking, and age. There was also an unexpected elevated risk of prostate cancer. Despite some methodological limitations, these findings underscore the need for assessing whether dermatological manifestations are also predictive of cardiovascular, respiratory, and other arsenic-related, long-term health consequences. Given the emerging evidence of arsenic exposure from dietary sources beyond contaminated drinking water and occupational and environmental settings, and also because the vast majority of diseases and deaths among exposed populations do not show classic dermatological manifestations, larger and more comprehensive investigations of the health effects of arsenic exposure, especially at lower doses, are needed. In parallel, because the risk of known arsenic-related health outcomes remains elevated decades after exposure cessation, research toward identification of early clinical and biological markers of long-term risk as well as avenues for prevention, in addition to policy actions for exposure reductions, is warranted.
arsenic; cancer; prevention; skin lesions
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.
Kidney Disease: Improving Global Outcomes (KDIGO); guideline; blood pressure
Smokeless tobacco is an alternative for smokers who want to quit but require nicotine. Reliable evidence on its effects is needed. Boffetta et al. and ourselves recently reviewed the evidence on cancer, based on Scandinavian and US studies. Boffetta et al. claimed a significant 60–80% increase for oropharyngeal, oesophageal and pancreatic cancer, and a non-significant 20% increase for lung cancer, data for other cancers being "too sparse". We found increases less than 15% for oesophageal, pancreatic and lung cancer, and a significant 36% increase for oropharyngeal cancer, which disappeared in recent studies. We found no association with stomach, bladder and all cancers combined, using data as extensive as that for oesophageal, pancreatic and lung cancer. We explain these differences.
For those cancers Boffetta et al. considered, we compared the methods, studies and risk estimates used in the two reviews.
One major reason for the difference is our more consistent approach in choosing between study-specific never smoker and combined smoker/non-smoker estimates. Another is our use of derived as well as published estimates. We included more studies, and avoided estimates for data subsets. Boffetta et al. also included some clearly biased or not smoking-adjusted estimates. For pancreatic cancer, their review included significantly increased never smoker estimates in one study and combined smoker/non-smoker estimates in another, omitting a combined estimate in the first study and a never smoker estimate in the second showing no increase. For oesophageal cancer, never smoker results from one study showing a marked increase for squamous cell carcinoma were included, but corresponding results for adenocarcinoma and combined smoker/non-smoker results for both cell types showing no increase were excluded. For oropharyngeal cancer, Boffetta et al. included a markedly elevated estimate that was not smoking-adjusted, and overlooked the lack of association in recent studies.
When conducting meta-analyses, all relevant data should be used, with clear rules governing the choice between alternative estimates. A systematic meta-analysis using pre-defined procedures and all relevant data gives a lower estimate of cancer risk from smokeless tobacco (probably 1–2% of that from smoking) than does the previous review by Boffetta et al.
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.
Chronic kidney disease; guideline; hyperparathyroidism; KDIGO; mineral and bone disorder
A meta-analytic review of the Triple P-Positive Parenting program by Wilson et al., recently published in BMC Medicine, claimed to demonstrate that although Triple P is widely disseminated and adopted, the evidence attesting to the effectiveness of the program is not as convincing as it may appear. Although this review addresses the important issue of evaluation and reporting methods within evidence-based interventions, we contend that the Wilson et al. review contains a number of significant conceptual, methodological and interpretational inadequacies that render the key conclusions of their review problematic.
Triple P; Public Health; Parenting; Evidence
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.
While chronic exposure to secondhand smoke has been well recognized as a cause of heart disease in nonsmokers, there has been recent speculation about the potential acute cardiovascular effects of transient exposure to secondhand smoke among nonsmokers; in particular, the possibility that such exposure could increase the risk of acute myocardial infarction even in an otherwise healthy nonsmoker. This paper reviews the claims being made by a number of anti-smoking and public health groups regarding the acute cardiovascular effects of secondhand smoke exposure among otherwise healthy adults, analyzes the validity of these claims based on a review of the scientific evidence, and discusses the implications of the findings for tobacco control and public health practice. Based on the analysis, it appears that a large number of anti-smoking organizations are making inaccurate claims that a single, acute, transient exposure to secondhand smoke can cause severe and even fatal cardiovascular events in healthy nonsmokers. The dissemination of inaccurate information by anti-smoking groups to the public in support of smoking bans is unfortunate because it may harm the tobacco control movement by undermining its credibility, reputation, and effectiveness. Disseminating inaccurate information also represents a violation of basic ethical principles that are a core value of public health practice that cannot and should not be sacrificed, even for a noble end such as protecting nonsmokers from secondhand smoke exposure. How the tobacco control movement responds to this crisis of credibility will go a long way towards determining the future effectiveness of the movement and its ability to continue to save lives and protect the public's health.
The interaction estimates from Bhavnani et al. (Am J Epidemiol. 2012;176(5):387–395) are used to evaluate evidence for mechanistic interaction between coinfecting pathogens for diarrheal disease. Mechanistic interaction is said to be present if there are individuals for whom the outcome would occur if both of 2 exposures are present but would not occur if 1 or the other of the exposures is absent. In the epidemiologic literature, mechanistic interaction is often conceived of as synergism within Rothman's sufficient-cause framework. Tests for additive interaction are sometimes used to assess such synergism or mechanistic interaction, but testing for positive additive interaction only allows for the conclusion of mechanistic interaction under fairly strong “monotonicity” assumptions. Alternative tests for mechanistic interaction, which do not require monotonicity assumptions, have been developed more recently but require more substantial additive interaction to draw the conclusion of the presence of mechanistic interaction. The additive interaction reported by Bhavnani et al. is of sufficient magnitude to provide strong evidence of mechanistic interaction between rotavirus and Giardia and between rotavirus and Escherichia. coli/Shigellae, even without any assumptions about monotonicity.
coinfecting pathogens; diarrhea; interaction; mechanism; synergism
Recent results from Võ and Wolfe (2012b) suggest that the application of memory to visual search may be task specific: Previous experience searching for an object facilitated later search for that object, but object information acquired during a different task did not appear to transfer to search. The latter inference depended on evidence that a preview task did not improve later search, but Võ and Wolfe used a relatively insensitive, between-subjects design. Here, we replicated the Võ and Wolfe study using a within-subject manipulation of scene preview. A preview session (focused either on object location memory or on the assessment of object semantics) reliably facilitated later search. In addition, information acquired from distractors in a scene facilitated search when the distractor later became the target. Instead of being strongly constrained by task, visual memory is applied flexibly to guide attention and gaze during visual search.
There have been notable contributions in the literature regarding the consensus for a new standard for the treatment of diabetic foot ulcers. The more recent advances in wound care therapies, modalities, and evidence-based research have demonstrated that an advanced standard of care for wound healing should exist. Failure of treatment protocols, which center on a 50% area of wound reduction within 4 weeks as a response to standard conventional care, should indicate the use of adjuvant therapies. Negative pressure wound therapy (NPWT), hyperbaric oxygen therapy (HBOT), growth factors, human-derived bioengineered tissue, and extracellular matrix products are readily available. This commentary will explore a brief selection of the current wound care literature as it relates to the acceptance of a new advanced standard of care. Furthermore, the intention is to stimulate further discussion and thought on the relevance of this approach in the treatment of diabetic foot ulcers and chronic wounds and how it may correlate with the ultimate outcome of healing in general.
Adjuvant therapy; Advanced standard of care; Bioengineered tissue; Chronic wounds; Diabetic ulcers; Extracellular matrix; HBOT; NPWT; Standard of care; Timely wound care; Wound healing; Wound management
Genome-wide linkage analysis studies in families with systemic lupus erythematosus (SLE) have revealed consistent evidence of linkage to several regions of the genome. In a previous issue of this journal, Graham and colleagues described their approach to following up the linkage data for one of these regions, 1q41–42. Using methods based on the transmission disequilibrium test, the region likely to harbour a SLE disease gene was refined to 2.3 Mb. This commentary discusses their approach and identifies lessons that may be applicable to the investigation of other complex diseases.
association; linkage; systemic lupus erythematosus; transmission disequilibrium test; whole-genome scan
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.