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Lebow J.,University of Miami | Wang Z.,Evidence Based Practice Center | Koball A.,Gundersen Lutheran Health System | Hassan Murad M.,Evidence Based Practice Center
Pediatrics | Year: 2016

Context: Although practice guidelines suggest that primary care providers working with children and adolescents incorporate BMI surveillance and counseling into routine practice, the evidence base for this practice is unclear. OBJECTIVE: To determine the effect of brief, primary care interventions for pediatric weight management on BMI. DATA SOURCES: Medline, CENTRAL, Embase, PsycInfo, and CINAHL were searched for relevant publications from January 1976 to March 2016 and cross-referenced with published studies. STUDY SELECTION: Eligible studies were randomized controlled trials and quasi-experimental studies that compared the effect of office-based primary care weight management interventions to any control intervention on percent BMI or BMI z scores in children aged 2 to 18 years. DATA EXTRACTION: Two reviewers independently screened sources, extracted data on participant, intervention, and study characteristics, z-BMI/percent BMI, harms, and study quality using the Cochrane and Newcastle-Ottawa risk of bias tools. RESULTS: A random effects model was used to pool the effect size across eligible 10 randomized controlled trials and 2 quasi-experimental studies. Compared with usual care or control treatment, brief interventions feasible for primary care were associated with a significant but small reduction in BMI z score (-0.04, [95% confidence interval,-0.08 to-0.01]; P =.02) and a nonsignificant effect on body satisfaction (standardized mean difference 0.00, [95% confidence interval,-0.21 to 0.22]; P =.98). LIMITATIONS: Studies had methodological limitations, follow-up was brief, and adverse effects were not commonly measured. CONCLUSIONS: BMI surveillance and counseling has a marginal effect on BMI, highlighting the need for revised practice guidelines and the development of novel approaches for providers to address this problem. © 2016 by the American Academy of Pediatrics.


Fraser J.G.,Boston Medical Center | Fraser J.G.,Rti International | Murphy R.,Center for Child and Family Health | Coker-Schwimmer E.,Evidence Based Practice Center | Viswanathan M.,Rti International
Journal of Developmental and Behavioral Pediatrics | Year: 2013

Objective: To systematically review the comparative effectiveness evidence for interventions to ameliorate the negative sequelae of maltreatment exposure in children ages birth to 14 years. Methods: We assessed the research on pharmacological and psychosocial interventions (parent-mediated approaches or trauma-focused treatments) reporting mental and behavioral health, caregiver-child relationship, and developmental and/or school functioning outcomes. We conducted focused searches of MEDLINE (through PubMed), Social Sciences Citation Index, PsycINFO, and the Cochrane Library (1990-2012). Reviewer pairs independently evaluated the studies for eligibility using predetermined inclusion/exclusion criteria, evaluated studies for risk of bias, extracted data, and graded the strength of evidence (SOE) for each comparison and each outcome based on predetermined criteria. Results: Based on our review of 6282 unduplicated citations, we found 17 trials eligible for inclusion. Although several interventions show promising comparative benefit for child well-being outcomes, the SOE for all but one of these interventions was low. The results highlight numerous substantive and methodological gaps to address in the future research. CONCLUSIONS:: It is too early to make strong treatment recommendations, as comparative research remains relatively nascent in the child maltreatment arena. These gaps reflect, in large part, the Herculean demands on researchers involved in conducting high-quality clinical studies with this highly vulnerable population. The National Child Traumatic Stress Network and the Developmental-Behavioral Pediatrics Research Network (DBPNet) are two potentially powerful platforms to conduct large rigorous trials needed to move the field forward. More broadly, a paradigm shift among researchers and funders alike is needed to galvanize the commitment and resources necessary for conducting collaborative clinical trials with this highly vulnerable population. © 2013 Lippincott Williams & Wilkins.


PubMed | University of Missouri, University of Michigan, Mayo Medical School, Aristotle University of Thessaloniki and Evidence based Practice Center
Type: Journal Article | Journal: Journal of vascular surgery | Year: 2016

The objective of this review was to synthesize the available randomized controlled trials (RCTs) estimating the relative efficacy and safety of intensive vs less intensive glycemic control in preventing diabetic foot syndrome.We used the umbrella design (systematic review of systematic reviews) to identify eligible RCTs. Two reviewers determined RCT eligibility and extracted descriptive, methodologic, and diabetic foot outcome data. Random-effects meta-analysis was used to pool outcome data across studies, and the I(2) statistic was used to quantify heterogeneity.Nine RCTs enrolling 10,897 patients with type 2 diabetes were included and deemed to be at moderate risk of bias. Compared with less intensive glycemic control, intensive control (hemoglobin A1c, 6%-7.5%) was associated with a significant decrease in risk of amputation (relative risk [RR], 0.65; 95% confidence interval [CI], 0.45-0.94; I(2) = 0%). Intensive control was significantly associated with slower decline in sensory vibration threshold (mean difference, -8.27; 95% CI, -9.75 to -6.79). There was no effect on other neuropathic changes (RR, 0.89; 95% CI, 0.75-1.05; I(2) = 32%) or ischemic changes (RR, 0.92; 95% CI, 0.67-1.26; I(2) = 0%). The quality of evidence is likely moderate.Compared with less intensive glycemic control therapy, intensive control may decrease the risk of amputation in patients with diabetic foot syndrome. The reported risk reduction is likely overestimated because the trials were open and the decision to proceed with amputation could be influenced by glycemic control.


PubMed | University of Missouri, Mayo Medical School, Aristotle University of Thessaloniki, University of Arizona and Evidence based Practice Center
Type: Journal Article | Journal: Journal of vascular surgery | Year: 2016

This systematic review summarized the evidence on noninvasive screening tests for the prediction of wound healing and the risk of amputation in diabetic foot ulcers.We searched MEDLINE In-Process & Other Non-Indexed Citations, MEDLINE, Embase, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, and Scopus from database inception to October 2011. We pooled sensitivity, specificity, and diagnostic odds ratio (DOR) and compared test performance.Thirty-seven studies met the inclusion criteria. Eight tests were used to predict wound healing in this setting, including ankle-brachial index (ABI), ankle peak systolic velocity, transcutaneous oxygen measurement (TcPo2), toe-brachial index, toe systolic blood pressure, microvascular oxygen saturation, skin perfusion pressure, and hyperspectral imaging. For the TcPo2 test, the pooled DOR was 15.81 (95% confidence interval [CI], 3.36-74.45) for wound healing and 4.14 (95% CI, 2.98-5.76) for the risk of amputation. ABI was also predictive but to a lesser degree of the risk of amputations (DOR, 2.89; 95% CI, 1.65-5.05) but not of wound healing (DOR, 1.02; 95% CI, 0.40-2.64). It was not feasible to perform meta-analysis comparing the remaining tests. The overall quality of evidence was limited by the risk of bias and imprecision (wide CIs due to small sample size).Several tests may predict wound healing in the setting of diabetic foot ulcer; however, most of the available evidence evaluates only TcPo2 and ABI. The overall quality of the evidence is low, and further research is needed to provide higher quality comparative effectiveness evidence.


PubMed | Phoenix VA Health Care System, Evidence based Practice Center, Mayo Medical School, Aristotle University of Thessaloniki and 2 more.
Type: Journal Article | Journal: Journal of vascular surgery | Year: 2016

Several methods of dbridement of diabetic foot ulcers are currently used. The relative efficacy of these methods is not well established.This systematic review and meta-analysis was conducted to find the best available evidence for the effect of dbridement on diabetic foot wound outcomes. We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Web of Science, and Scopus through October 2011 for randomized controlled studies (RCTs) and observational comparative studies.We identified 11 RCTs and three nonrandomized studies reporting on 800 patients. The risk of bias was moderate overall. Meta-analysis of three RCTs showed that autolytic dbridement significantly increased the healing rate (relative risk [RR], 1.89; 95% confidence interval [CI] 1.35-2.64). Meta-analysis of four studies (one RCT) showed that larval dbridement reduced amputation (RR, 0.43; 95% CI, 0.21-0.88) but did not increase complete healing (RR, 1.27; 95% CI, 0.84-1.91). Surgical dbridement was associated with shorter healing time compared with conventional wound care (one RCT). Insufficient evidence was found for comparisons between autolytic and larval dbridement (one RCT), between ultrasound-guided and surgical dbridement, and between hydrosurgical and surgical dbridement.The available literature supports the efficacy of several dbridement methods, including surgical, autolytic, and larval dbridement. Comparative effectiveness evidence between these methods and supportive evidence for other methods is of low quality due to methodologic limitations and imprecision. Hence, the choice of dbridement method at the present time should be based on the available expertise, patient preferences, the clinical context and cost.


Foy R.,University of Leeds | Hempel S.,Evidence based Practice Center | Rubenstein L.,RAND Health | Suttorp M.,Evidence based Practice Center | And 3 more authors.
Annals of Internal Medicine | Year: 2010

Background: Whether collaborative care models that enable interactive communication (timely, 2-way exchange of pertinent clinical information directly between primary care and specialist physicians) improve patient outcomes is uncertain. Purpose: To assess the effects of interactive communication between collaborating primary care physicians and key specialists on outcomes for patients receiving ambulatory care. Data Sources: PubMed, PsycInfo, EMBASE, CINAHL, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, and Web of Science through June 2008 and secondary references, with no language restriction. Study Selection: Studies that evaluated the effects of interactive communication between collaborating primary care physicians and specialists on outcomes for patients with diabetes, psychiatric conditions, or cancer. Data Extraction: Contextual, intervention, and outcome data from 23 studies were extracted by one reviewer and checked by another. Study quality was assessed with a 13-item checklist. Disagreement was resolved by consensus. Main outcomes for analysis were selected by reviewers who were blinded to study results. Data Synthesis: Meta-analysis indicated consistent effects across 11 randomized mental health studies (pooled effect size, -0.41 [95% CI, -0.73 to -0.10]), 7 nonrandomized mental health studies (pooled effect size, -0.47 [CI, -0.84 to -0.09]), and 5 nonrandomized diabetes studies (pooled effect size, -0.64 [CI, -0.93 to -0.34]). These findings remained robust to sensitivity analyses. Meta-regression indicated studies that included interventions to enhance the quality of information exchange had larger effects on patient outcomes than those that did not (-0.84 vs. -0.27; P = 0.002). Limitations: Because collaborative interventions were inherently multifaceted, the efficacy of interactive communication by itself cannot be established. Inclusion of study designs with lower internal validity increased risk for bias. No studies involved oncologists. Conclusion: Consistent and clinically important effects suggest a potential role of interactive communication for improving the effectiveness of primary care-specialist collaboration. Primary Funding Source: RAND Health's Comprehensive Assessment of Reform Options Initiative, the Veterans Affairs Center for the Study of Provider Behavior, The Commonwealth Fund, and the Health Foundation. © 2010 American College of Physicians.


Mainou M.,Evidence Based Practice Center | Alahdab F.,Evidence Based Practice Center | Tobian A.A.R.,Johns Hopkins University | Asi N.,Evidence Based Practice Center | And 3 more authors.
Transfusion | Year: 2016

BACKGROUND Leukoreduced (LR) or cytomegalovirus (CMV)-seronegative cellular blood components are commonly used to reduce the risk of transfusion-transmitted CMV infection in high-risk patients. STUDY DESIGN AND METHODS We performed a systematic review and meta-analysis to evaluate the evidence for the use of LR cellular blood components with or without concurrent CMV testing of donor units in patients undergoing chemotherapy or solid organ and hematopoietic stem cell transplantation, in pregnant women, in very-low-birthweight infants, and in patients with primary immunodeficiency. We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus from 1980 through February 2015. Studies were included if they had a comparison group. Two independent reviewers selected and appraised studies. Meta-analysis was performed when appropriate. RESULTS Of 457 studies screened, 11 were eligible. One study was excluded from the meta-analysis because the comparison performed differed significantly from the others. Meta-analysis of five studies that compared leukoreduction to transfusing CMV-untested blood components showed no significant difference in clinical CMV infection (relative risk [RR], 0.26; 95% confidence interval [CI], 0.04-1.57) or laboratory CMV infection (RR, 0.33; 95% CI, 0.08-1.37). Meta-analysis of three studies that compared leukoreduction to transfusing CMV-seronegative cellular components showed no significant difference in laboratory CMV infection (RR, 2.18; 95% CI, 0.96-4.98). Meta-analysis of two studies that compared adding CMV testing to leukoreduction (vs. leukoreduction alone) showed no significant difference in clinical or laboratory CMV infection. The certainty in estimates was low for all comparisons. CONCLUSION At present, the scientific evidence does not favor a single strategy for reducing the risk of transfusion-related CMV infection in high-risk patients. © 2016 AABB.


Guise J.-M.,3710 Sw Us Veterans Hospital Road | Chang C.,Agency for Healthcare Research and Quality | Viswanathan M.,Evidence based Practice Center | Glick S.,Blue Cross Blue Shield Evidence based Practice Center | And 9 more authors.
Journal of Clinical Epidemiology | Year: 2014

Objectives The purpose of this Agency for Healthcare Research and Quality Evidence-based Practice Center methods white paper was to outline approaches to conducting systematic reviews of complex multicomponent health care interventions.Study Design and Setting We performed a literature scan and conducted semistructured interviews with international experts who conduct research or systematic reviews of complex multicomponent interventions (CMCIs) or organizational leaders who implement CMCIs in health care.Results Challenges identified include lack of consistent terminology for such interventions (eg, complex, multicomponent, multidimensional, multifactorial); a wide range of approaches used to frame the review, from grouping interventions by common features to using more theoretical approaches; decisions regarding whether and how to quantitatively analyze the interventions, from holistic to individual component analytic approaches; and incomplete and inconsistent reporting of elements critical to understanding the success and impact of multicomponent interventions, such as methods used for implementation the context in which interventions are implemented.Conclusion We provide a framework for the spectrum of conceptual and analytic approaches to synthesizing studies of multicomponent interventions and an initial list of critical reporting elements for such studies. This information is intended to help systematic reviewers understand the options and tradeoffs available for such reviews. © 2014 Elsevier Inc.


PubMed | Maternity and Children Hospital and Evidence Based Practice Center
Type: | Journal: Journal of pediatric surgery | Year: 2017

Posterior sagittal anorectoplasty (PSARP) published by DeVries and Pea in 1982 had become the preferred surgical technique for the management of anorectal malformations (ARM). The original technique is based upon complete exposure of the anorectal region by means of a median sagittal incision that runs from the sacrum to the anal dimple, cutting through all muscle structures behind the rectum by dividing the levator muscle and the muscle complex. Then, the rectum is located in front of the levator and within the limits of the muscle complex. In this review, we described Muscle Complex Saving-Posterior Sagittal Anorectoplasty (MCS-PSARP), which is a less invasive technique that consists of keeping this funnel-shaped muscle complex completely intact and not divided, and pulling the rectum through this funnel, toward fixing the new anus to the skin. This technique aimed both to respect the lower part of the sphincter mechanism consisting of the muscle complex, and to avoid the disturbance of this important structure by dividing and resuturing it.We presented six cases of male patients who were born with anorectal malformation (ARM) and underwent MCS-PSARP. The surgical technique proved to be feasible to achieve the dissection of the rectal pouch and the division of the rectourethral fistula in all patients, by opening only the upper part of the sphincter mechanism, the levator muscle, and keeping the lower part consisting of intact muscle complex.The early results in our series are encouraging; however, long-term functional outcomes of these patients are awaited. The surgical tips were also discussed.This proposed approach in the management of anorectal malformation cases provides an opportunity to maximize preservation of the existing continence mechanisms. It preserves the muscle complex components of the levator muscle intact, allowing a better function of the continence mechanism.


PubMed | Mayo Medical School and Evidence based Practice Center
Type: | Journal: Journal of the American College of Radiology : JACR | Year: 2016

Many studies have suggested that disparities exist in the use of medical screening tests. The purpose of this study was to assess racial disparities in screening mammography in the United States via a systematic review and meta-analysis.We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus for comparative studies published between 1946 and 2015 comparing utilization of mammography among various racial groups. Two independent reviewers extracted data and appraised study. Meta-analysis was conducted when appropriate using the random-effects model.A total of 5,818,380 patients were included across 39 relevant studies; 43.1% of patients were white, 33.3% were black, 17.4% were Hispanic, and 6.2% were Asian/Pacific Islander. Black and Hispanic populations had lower odds of utilizing screening mammography when compared with the white population (odds ratio [OR]= 0.81; 95% confidence interval [CI], 0.72-0.91; IRacial disparities in utilization of screening mammography are evident in black and Hispanic populations in the United States. Further studies are needed to understand reasons for disparities, trends over time, and the effectiveness of interventions targeting these disparities.

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