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Schiller CE, Prim J, Bauer AE, Lux L, Lundegard LC, Kang M, Hellberg S, Thompson K, Webber T, Teklezghi A, Pettee N, Gaffney K, Hodgins G, Rahman F, Steinsiek JN, Modi A, Gaynes BN. Efficacy of Virtual Care for Depressive Disorders: Systematic Review and Meta-analysis. JMIR Ment Health 2023; 10:e38955. [PMID: 36622747 PMCID: PMC9871881 DOI: 10.2196/38955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 08/03/2022] [Accepted: 08/18/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic has created an epidemic of distress-related mental disorders such as depression, while simultaneously necessitating a shift to virtual domains of mental health care; yet, the evidence to support the use of virtual interventions is unclear. OBJECTIVE The purpose of this study was to evaluate the efficacy of virtual interventions for depressive disorders by addressing three key questions: (1) Does virtual intervention provide better outcomes than no treatment or other control conditions (ie, waitlist, treatment as usual [TAU], or attention control)? (2) Does in-person intervention provide better outcomes than virtual intervention? (3) Does one type of virtual intervention provide better outcomes than another? METHODS We searched the PubMed, EMBASE, and PsycINFO databases for trials published from January 1, 2010, to October 30, 2021. We included randomized controlled trials of adults with depressive disorders that tested a virtual intervention and used a validated depression measure. Primary outcomes were defined as remission (ie, no longer meeting the clinical cutoff for depression), response (ie, a clinically significant reduction in depressive symptoms), and depression severity at posttreatment. Two researchers independently selected studies and extracted data using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Risk of bias was evaluated based on Agency for Healthcare and Research Quality guidelines. We calculated odds ratios (ORs) for binary outcomes and standardized mean differences (SMDs) for continuous outcomes. RESULTS We identified 3797 references, 24 of which were eligible. Compared with waitlist, virtual intervention had higher odds of remission (OR 10.30, 95% CI 5.70-18.60; N=619 patients) and lower posttreatment symptom severity (SMD 0.81, 95% CI 0.52-1.10; N=1071). Compared with TAU and virtual attention control conditions, virtual intervention had higher odds of remission (OR 2.27, 95% CI 1.10-3.35; N=512) and lower posttreatment symptom severity (SMD 0.25, 95% CI 0.09-0.42; N=573). In-person intervention outcomes were not significantly different from virtual intervention outcomes (eg, remission OR 0.84, CI 0.51-1.37; N=789). No eligible studies directly compared one active virtual intervention to another. CONCLUSIONS Virtual interventions were efficacious compared with control conditions, including waitlist control, TAU, and attention control. Although the number of studies was relatively small, the strength of evidence was moderate that in-person interventions did not yield significantly better outcomes than virtual interventions for depressive disorders.
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Affiliation(s)
- Crystal Edler Schiller
- Department of Psychiatry, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Julianna Prim
- Department of Psychiatry, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Anna E Bauer
- Department of Psychiatry, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Linda Lux
- Department of Psychiatry, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Laura Claire Lundegard
- Department of Psychiatry, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Michelle Kang
- Department of Psychiatry, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Samantha Hellberg
- Department of Psychiatry, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Katherine Thompson
- Department of Psychiatry, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Theresa Webber
- Department of Psychiatry, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Adonay Teklezghi
- Department of Psychiatry, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Noah Pettee
- Department of Psychiatry, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Katherine Gaffney
- Department of Psychiatry, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Gabrielle Hodgins
- Department of Psychiatry, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Fariha Rahman
- Department of Psychiatry, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - J Nikki Steinsiek
- Department of Psychiatry, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Anita Modi
- Department of Psychiatry, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Bradley N Gaynes
- Department of Psychiatry, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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Gaynes BN, Lux L, Gartlehner G, Asher G, Forman-Hoffman V, Green J, Boland E, Weber RP, Randolph C, Bann C, Coker-Schwimmer E, Viswanathan M, Lohr KN. Defining treatment-resistant depression. Depress Anxiety 2020; 37:134-145. [PMID: 31638723 DOI: 10.1002/da.22968] [Citation(s) in RCA: 156] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 08/16/2019] [Accepted: 10/04/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Varying conceptualizations of treatment-resistant depression (TRD) have made translating research findings or systematic reviews into clinical practice guidelines challenging and inconsistent. METHODS We conducted a review for the Centers for Medicare & Medicaid Services and the Agency for Healthcare Research and Quality to clarify how experts and investigators have defined TRD and to review systematically how well this definition comports with TRD definitions in clinical trials through July 5, 2019. RESULTS We found that no consensus definition existed for TRD. The most common TRD definition for major depressive disorder required a minimum of two prior treatment failures and confirmation of prior adequate dose and duration. The most common TRD definition for bipolar disorder required one prior treatment failure. No clear consensus emerged on defining adequacy of either dose or duration. Our systematic review found that only 17% of intervention studies enrolled samples meeting the most frequently specified criteria for TRD. Depressive outcomes and clinical global impressions were commonly measured; functional impairment and quality-of-life tools were rarely used. CONCLUSIONS Two key steps are critical to advancing TRD research: (a) Developing a consensus definition of TRD that addresses how best to specify the number of prior treatment failures and the adequacy of dose and duration; and (b) identifying a core package of outcome measures that can be applied in a standardized manner. Our recommendations about stronger approaches to designing and conducting TRD research will foster better evidence to translate into clearer guidelines for treating patients with this serious condition.
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Affiliation(s)
- Bradley N Gaynes
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Linda Lux
- RTI International, The RTI International-University of North Carolina Evidence-based Practice Center, Durham, North Carolina
| | - Gerald Gartlehner
- RTI International, The RTI International-University of North Carolina Evidence-based Practice Center, Durham, North Carolina.,Department for Evidence-Based Medicine and Clinical Epidemiology, Danube University, Krems, Austria
| | - Gary Asher
- Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Valerie Forman-Hoffman
- RTI International, The RTI International-University of North Carolina Evidence-based Practice Center, Durham, North Carolina
| | - Josh Green
- RTI International, The RTI International-University of North Carolina Evidence-based Practice Center, Durham, North Carolina
| | - Erin Boland
- RTI International, The RTI International-University of North Carolina Evidence-based Practice Center, Durham, North Carolina
| | - Rachel P Weber
- Sheps Center for Health Services Research, The RTI International-University of North Carolina Evidence-based Practice Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Charli Randolph
- Sheps Center for Health Services Research, The RTI International-University of North Carolina Evidence-based Practice Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Carla Bann
- RTI International, The RTI International-University of North Carolina Evidence-based Practice Center, Durham, North Carolina
| | - Emmanuel Coker-Schwimmer
- Sheps Center for Health Services Research, The RTI International-University of North Carolina Evidence-based Practice Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Meera Viswanathan
- RTI International, The RTI International-University of North Carolina Evidence-based Practice Center, Durham, North Carolina
| | - Kathleen N Lohr
- RTI International, The RTI International-University of North Carolina Evidence-based Practice Center, Durham, North Carolina
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Gartlehner G, Wagner G, Lux L, Affengruber L, Dobrescu A, Kaminski-Hartenthaler A, Viswanathan M. Assessing the accuracy of machine-assisted abstract screening with DistillerAI: a user study. Syst Rev 2019; 8:277. [PMID: 31727159 PMCID: PMC6857277 DOI: 10.1186/s13643-019-1221-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 11/05/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Web applications that employ natural language processing technologies to support systematic reviewers during abstract screening have become more common. The goal of our project was to conduct a case study to explore a screening approach that temporarily replaces a human screener with a semi-automated screening tool. METHODS We evaluated the accuracy of the approach using DistillerAI as a semi-automated screening tool. A published comparative effectiveness review served as the reference standard. Five teams of professional systematic reviewers screened the same 2472 abstracts in parallel. Each team trained DistillerAI with 300 randomly selected abstracts that the team screened dually. For all remaining abstracts, DistillerAI replaced one human screener and provided predictions about the relevance of records. A single reviewer also screened all remaining abstracts. A second human screener resolved conflicts between the single reviewer and DistillerAI. We compared the decisions of the machine-assisted approach, single-reviewer screening, and screening with DistillerAI alone against the reference standard. RESULTS The combined sensitivity of the machine-assisted screening approach across the five screening teams was 78% (95% confidence interval [CI], 66 to 90%), and the combined specificity was 95% (95% CI, 92 to 97%). By comparison, the sensitivity of single-reviewer screening was similar (78%; 95% CI, 66 to 89%); however, the sensitivity of DistillerAI alone was substantially worse (14%; 95% CI, 0 to 31%) than that of the machine-assisted screening approach. Specificities for single-reviewer screening and DistillerAI were 94% (95% CI, 91 to 97%) and 98% (95% CI, 97 to 100%), respectively. Machine-assisted screening and single-reviewer screening had similar areas under the curve (0.87 and 0.86, respectively); by contrast, the area under the curve for DistillerAI alone was just slightly better than chance (0.56). The interrater agreement between human screeners and DistillerAI with a prevalence-adjusted kappa was 0.85 (95% CI, 0.84 to 0.86%). CONCLUSIONS The accuracy of DistillerAI is not yet adequate to replace a human screener temporarily during abstract screening for systematic reviews. Rapid reviews, which do not require detecting the totality of the relevant evidence, may find semi-automation tools to have greater utility than traditional systematic reviews.
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Affiliation(s)
- Gerald Gartlehner
- RTI International-University of North Carolina Evidence-based Practice Center, Research Triangle Park, NC, USA.
- Department for Evidence-based Medicine and Evaluation, Danube University Krems, Krems, Austria.
| | - Gernot Wagner
- Department for Evidence-based Medicine and Evaluation, Danube University Krems, Krems, Austria
| | - Linda Lux
- RTI International-University of North Carolina Evidence-based Practice Center, Research Triangle Park, NC, USA
| | - Lisa Affengruber
- Department for Evidence-based Medicine and Evaluation, Danube University Krems, Krems, Austria
- Department of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Andreea Dobrescu
- Department for Evidence-based Medicine and Evaluation, Danube University Krems, Krems, Austria
| | | | - Meera Viswanathan
- RTI International-University of North Carolina Evidence-based Practice Center, Research Triangle Park, NC, USA
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Lepore M, Greene AM, Porter K, Lux L, Vreeland E, Hawes C. Unlicensed care homes in the United States: a clandestine sector of long-term care. J Aging Soc Policy 2018; 31:49-65. [DOI: 10.1080/08959420.2018.1485397] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Affiliation(s)
- Michael Lepore
- Aging, Disability and Long-term Care, RTI International, Research Triangle Park, North Carolina, USA
| | - Angela M. Greene
- Aging, Disability and Long-term Care, RTI International, Research Triangle Park, North Carolina, USA
| | - Kristie Porter
- Aging, Disability and Long-term Care, RTI International, Research Triangle Park, North Carolina, USA
| | - Linda Lux
- Aging, Disability and Long-term Care, RTI International, Research Triangle Park, North Carolina, USA
| | - Emily Vreeland
- Aging, Disability and Long-term Care, RTI International, Research Triangle Park, North Carolina, USA
| | - Catherine Hawes
- Health Policy & Management, Texas A&M, Research Triangle Park, North Carolina, USA
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Gartlehner G, Patel SV, Feltner C, Weber RP, Long R, Mullican K, Boland E, Lux L, Viswanathan M. Hormone Therapy for the Primary Prevention of Chronic Conditions in Postmenopausal Women: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2017; 318:2234-2249. [PMID: 29234813 DOI: 10.1001/jama.2017.16952] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Postmenopausal status coincides with increased risks for chronic conditions such as heart disease, osteoporosis, cognitive impairment, or some types of cancers. Previously, hormone therapy was used for the primary prevention of these chronic conditions. OBJECTIVE To update evidence for the US Preventive Services Task Force on the benefits and harms of hormone therapy in reducing risks for chronic conditions. DATA SOURCES MEDLINE, Cochrane Library, EMBASE, and trial registries from June 1, 2011, through August 1, 2016. Surveillance for new evidence in targeted publications was conducted through July 1, 2017. STUDY SELECTION English-language randomized clinical trials reporting health outcomes. DATA EXTRACTION AND SYNTHESIS Dual review of abstracts, full-text articles, and study quality; meta-analyses when at least 3 similar studies were available. MAIN OUTCOMES AND MEASURES Beneficial or harmful changes in risks for various chronic conditions. RESULTS Eighteen trials (n = 40 058; range, 142-16 608; mean age, 53-79 years) were included. Women using estrogen-only therapy compared with placebo had significantly lower risks, per 10 000 person-years, for diabetes (-19 cases [95% CI, -34 to -3]) and fractures (-53 cases [95% CI, -69 to -39]). Risks were statistically significantly increased, per 10 000 person-years, for gallbladder disease (30 more cases [95% CI, 16 to 48]), stroke (11 more cases [95% CI, 2 to 23]), venous thromboembolism (11 more cases [95% CI, 3 to 22]), and urinary incontinence (1261 more cases [95% CI, 880 to 1689]). Women using estrogen plus progestin compared with placebo experienced significantly lower risks, per 10 000 person-years, for colorectal cancer (-6 cases [95% CI, -9 to -1]), diabetes (-14 cases [95% CI, -24 to -3), and fractures (-44 cases [95% CI, -71 to -13). Risks, per 10 000 person-years, were significantly increased for invasive breast cancer (9 more cases [95% CI, 1 to 19]), probable dementia (22 more cases [95% CI, 4 to 53]), gallbladder disease (21 more cases [95% CI, 10 to 34]), stroke (9 more cases [95% CI, 2 to 19]), urinary incontinence (876 more cases [95% CI, 606 to 1168]), and venous thromboembolism (21 more cases [95% CI, 12 to 33]). CONCLUSIONS AND RELEVANCE Hormone therapy for the primary prevention of chronic conditions in menopausal women is associated with some beneficial effects but also with a substantial increase of risks for harms. The available evidence regarding benefits and harms of early initiation of hormone therapy is inconclusive.
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Affiliation(s)
- Gerald Gartlehner
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Department for Evidence-based Medicine and Clinical Epidemiology, Danube University Krems, Krems, Austria
| | - Sheila V Patel
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Cynthia Feltner
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
- Department of Medicine, University of North Carolina at Chapel Hill
| | - Rachel Palmieri Weber
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Rachel Long
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Eshelman School of Pharmacy, University of North Carolina at Chapel Hill
| | - Kelly Mullican
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- Eshelman School of Pharmacy, University of North Carolina at Chapel Hill
| | - Erin Boland
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Linda Lux
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
| | - Meera Viswanathan
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center
- RTI International, Research Triangle Park, North Carolina
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Gartlehner G, Wagner G, Matyas N, Titscher V, Greimel J, Lux L, Gaynes BN, Viswanathan M, Patel S, Lohr KN. Pharmacological and non-pharmacological treatments for major depressive disorder: review of systematic reviews. BMJ Open 2017; 7:e014912. [PMID: 28615268 PMCID: PMC5623437 DOI: 10.1136/bmjopen-2016-014912] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 03/16/2017] [Accepted: 04/27/2017] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES This study aims to summarise the evidence on more than 140 pharmacological and non-pharmacological treatment options for major depressive disorder (MDD) and to evaluate the confidence that patients and clinicians can have in the underlying science about their effects. DESIGN This is a review of systematic reviews. DATA SOURCES This study used MEDLINE, Embase, Cochrane Library, PsycINFO and Epistemonikos from 2011 up to February 2017 for systematic reviews of randomised controlled trials in adult patients with acute-phase MDD. METHODS We dually reviewed abstracts and full-text articles, rated the risk of bias of eligible systematic reviews and graded the strength of evidence. RESULTS Nineteen systematic reviews provided data on 28 comparisons of interest. For general efficacy, only second-generation antidepressants were supported with high strength evidence, presenting small beneficial treatment effects (standardised mean difference: -0.35; 95% CI -0.31 to -0.38), and a statistically significantly higher rate of discontinuation because of adverse events than patients on placebo (relative risk (RR) 1.88; 95% CI 1.0 to 3.28).Only cognitive behavioural therapy is supported by reliable evidence (moderate strength of evidence) to produce responses to treatment similar to those of second-generation antidepressants (45.5% vs 44.2%; RR 1.10; 95% CI 0.93 to 1.30). All remaining comparisons of non-pharmacological treatments with second-generation antidepressants either led to inconclusive results or had substantial methodological shortcomings (low or insufficient strength of evidence). CONCLUSIONS In contrast to pharmacological treatments, the majority of non-pharmacological interventions for treating patients with MDD are not evidence based. For patients with strong preferences against pharmacological treatments, clinicians should focus on therapies that have been compared directly with antidepressants. TRIAL REGISTRATION NUMBER International Prospective Register of Systematic Reviews (PROSPERO) registration number: 42016035580.
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Affiliation(s)
- Gerald Gartlehner
- Department for Evidence-based Medicine and Clinical Epidemiology, Danube University Krems, Krems, Austria
- RTI-University of North Carolina Evidence-based Practice Center, RTI International, North Carolina, USA
| | - Gernot Wagner
- Department for Evidence-based Medicine and Clinical Epidemiology, Danube University Krems, Krems, Austria
| | - Nina Matyas
- Department for Evidence-based Medicine and Clinical Epidemiology, Danube University Krems, Krems, Austria
| | - Viktoria Titscher
- Department for Evidence-based Medicine and Clinical Epidemiology, Danube University Krems, Krems, Austria
| | | | - Linda Lux
- RTI-University of North Carolina Evidence-based Practice Center, RTI International, North Carolina, USA
| | - Bradley N Gaynes
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Meera Viswanathan
- RTI-University of North Carolina Evidence-based Practice Center, RTI International, North Carolina, USA
| | - Sheila Patel
- RTI-University of North Carolina Evidence-based Practice Center, RTI International, North Carolina, USA
| | - Kathleen N Lohr
- RTI-University of North Carolina Evidence-based Practice Center, RTI International, North Carolina, USA
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Jonas DE, Amick HR, Feltner C, Weber RP, Arvanitis M, Stine A, Lux L, Harris RP. Screening for Obstructive Sleep Apnea in Adults: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2017; 317:415-433. [PMID: 28118460 DOI: 10.1001/jama.2016.19635] [Citation(s) in RCA: 178] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Many adverse health outcomes are associated with obstructive sleep apnea (OSA). OBJECTIVE To review primary care-relevant evidence on screening adults for OSA, test accuracy, and treatment of OSA, to inform the US Preventive Services Task Force. DATA SOURCES MEDLINE, Cochrane Library, EMBASE, and trial registries through October 2015, references, and experts, with surveillance of the literature through October 5, 2016. STUDY SELECTION English-language randomized clinical trials (RCTs); studies evaluating accuracy of screening questionnaires or prediction tools, diagnostic accuracy of portable monitors, or association between apnea-hypopnea index (AHI) and health outcomes among community-based participants. DATA EXTRACTION AND SYNTHESIS Two investigators independently reviewed abstracts and full-text articles. When multiple similar studies were available, random-effects meta-analyses were conducted. MAIN OUTCOMES AND MEASURES Sensitivity, specificity, area under the curve (AUC), AHI, Epworth Sleepiness Scale (ESS) scores, blood pressure, mortality, cardiovascular events, motor vehicle crashes, quality of life, and harms. RESULTS A total of 110 studies were included (N = 46 188). No RCTs compared screening with no screening. In 2 studies (n = 702), the screening accuracy of the multivariable apnea prediction score followed by home portable monitor testing for detecting severe OSA syndrome (AHI ≥30 and ESS score >10) was AUC 0.80 (95% CI, 0.78 to 0.82) and 0.83 (95% CI, 0.77 to 0.90), respectively, but the studies oversampled high-risk participants and those with OSA and OSA syndrome. No studies prospectively evaluated screening tools to report calibration or clinical utility for improving health outcomes. Meta-analysis found that continuous positive airway pressure (CPAP) compared with sham was significantly associated with reduction of AHI (weighted mean difference [WMD], -33.8 [95% CI, -42.0 to -25.6]; 13 trials, 543 participants), excessive sleepiness assessed by ESS score (WMD, -2.0 [95% CI, -2.6 to -1.4]; 22 trials, 2721 participants), diurnal systolic blood pressure (WMD, -2.4 points [95% CI, -3.9 to -0.9]; 15 trials, 1190 participants), and diurnal diastolic blood pressure (WMD, -1.3 points [95% CI, -2.2 to -0.4]; 15 trials, 1190 participants). CPAP was associated with modest improvement in sleep-related quality of life (Cohen d, 0.28 [95% CI, 0.14 to 0.42]; 13 trials, 2325 participants). Mandibular advancement devices (MADs) and weight loss programs were also associated with reduced AHI and excessive sleepiness. Common adverse effects of CPAP and MADs included oral or nasal dryness, irritation, and pain, among others. In cohort studies, there was a consistent association between AHI and all-cause mortality. CONCLUSIONS AND RELEVANCE There is uncertainty about the accuracy or clinical utility of all potential screening tools. Multiple treatments for OSA reduce AHI, ESS scores, and blood pressure. Trials of CPAP and other treatments have not established whether treatment reduces mortality or improves most other health outcomes, except for modest improvement in sleep-related quality of life.
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Affiliation(s)
- Daniel E Jonas
- Department of Medicine, University of North Carolina at Chapel Hill2RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center3Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Halle R Amick
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center3Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Cynthia Feltner
- Department of Medicine, University of North Carolina at Chapel Hill2RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center3Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Rachel Palmieri Weber
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center3Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
| | - Marina Arvanitis
- Department of Medicine, University of North Carolina at Chapel Hill3Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill4Now with the Department of Medicine, Northwestern University, Chicago, Illinois
| | - Alexander Stine
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center5RTI International, Research Triangle Park, North Carolina6Now with the Center for Cognitive Neuroscience, Duke University, Durham, North Carolina
| | - Linda Lux
- RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center5RTI International, Research Triangle Park, North Carolina
| | - Russell P Harris
- Department of Medicine, University of North Carolina at Chapel Hill2RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center3Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill
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Reichenpfader U, Gartlehner G, Morgan LC, Greenblatt A, Nussbaumer B, Hansen RA, Van Noord M, Lux L, Gaynes BN. Sexual dysfunction associated with second-generation antidepressants in patients with major depressive disorder: results from a systematic review with network meta-analysis. Drug Saf 2014; 37:19-31. [PMID: 24338044 DOI: 10.1007/s40264-013-0129-4] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Sexual dysfunction (SD) is prevalent in patients with major depressive disorder (MDD) and is also associated with second-generation antidepressants (SGADs) that are commonly used to treat the condition. Evidence indicates under-reporting of SD in efficacy studies. SD associated with antidepressant treatment is a serious side effect that may lead to early termination of treatment and worsening of quality of life. OBJECTIVES Our objective was to systematically assess the harms of SD associated with SGADs in adult patients with MDD by drug type. METHODS We retrieved English-language abstracts from PubMed, EMBASE, the Cochrane Library, PsycINFO, and International Pharmaceutical Abstracts from 1980 to October 2012 as well as from reference lists of pertinent review articles and grey literature searches. Two independent reviewers identified randomized controlled trials (RCTs) of at least 6 weeks' duration and observational studies with at least 1,000 participants. STUDY SELECTION Reviewers abstracted data on study design, conduct, participants, interventions, outcomes and method of SD ascertainment, and rated risk of bias. A senior reviewer checked and confirmed extracted data and risk-of-bias ratings. ANALYSES Random effects network meta-analysis using Bayesian methods for data from head-to-head trials and placebo-controlled comparisons; descriptive analyses calculating weighted mean rates from individual trials and observational studies. RESULTS/SYNTHESIS Data from 63 studies of low and moderate risk of bias (58 RCTs, five observational studies) with more than 26,000 patients treated with SGADs were included. Based on network meta-analyses of 66 pairwise comparisons from 37 RCTs, most comparisons showed a similar risk of SD among included SGADs. However, credible intervals were wide and included differences that would be considered clinically relevant. We observed three main patterns: bupropion had a statistically significantly lower risk of SD than some other SGADs, and both escitalopram and paroxetine showed a statistically significantly higher risk of SD than some other SGADs. We found reporting of harms related to SD inconsistent and insufficient in some trials. LIMITATIONS Most trials were conducted in highly selected populations. Search was restricted to English-language only. CONCLUSION AND IMPLICATIONS Because of the indirect nature of the comparisons, the often wide credible intervals, and the high variation in magnitude of outcome, we rated the overall strength of evidence with respect to our findings as low. The current degree of evidence does not allow a precise estimate of comparative risk of SD associated with a specific antidepressant. In the absence of such evidence, clinicians need to be aware of SD as a common adverse event and should discuss patients' preferences before initiating antidepressant therapy.
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Affiliation(s)
- Ursula Reichenpfader
- Department for Evidence-based Medicine and Clinical Epidemiology, Danube University Krems, Dr.-Karl-Dorrek-Str. 30, 3500, Krems, Austria,
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Nussbaumer B, Morgan LC, Reichenpfader U, Greenblatt A, Hansen RA, Van Noord M, Lux L, Gaynes BN, Gartlehner G. Comparative efficacy and risk of harms of immediate- versus extended-release second-generation antidepressants: a systematic review with network meta-analysis. CNS Drugs 2014; 28:699-712. [PMID: 24794101 DOI: 10.1007/s40263-014-0169-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Major depressive disorder (MDD) has detrimental effects on an individual's personal life, leads to increased risk of comorbidities, and places an enormous economic burden on society. Several 'second-generation' antidepressants are available as both immediate-release (IR) and extended-release formulations. The advantage of extended-release formulations may be the potentially improved adherence and a lower risk of adverse events. OBJECTIVE We conducted a systematic review to assess the comparative efficacy, risk of harms, and patients' adherence of IR and extended-release antidepressants for the treatment of MDD. DATA SOURCE English-language abstracts were retrieved from PubMed, EMBASE, the Cochrane Library, PsycINFO, and International Pharmaceutical Abstracts from 1980 to October 2012, as well as from reference lists of pertinent review articles and grey literature searches. ELIGIBILITY CRITERIA We included head-to-head randomized controlled trials (RCTs) of at least 6 weeks' duration that compared an IR formulation with an extended-release formulation of the same antidepressant in adult patients with MDD. We also included placebo-controlled trials to conduct a network meta-analysis. To assess harms and adherence, in addition to RCTs, we searched for observational studies with ≥1,000 participants and a follow-up of ≥12 weeks. STUDY APPRAISAL AND SYNTHESIS METHODS We dually reviewed abstracts and full texts and assessed quality ratings. Lacking head-to-head evidence for many comparisons of interest, we conducted network meta-analyses using Bayesian methods. Our outcome measure of choice was response on the Hamilton Depression Rating Scale. RESULTS We located seven head-to-head trials and 94 placebo- and active-controlled trials for network meta-analysis. Overall, our analyses indicate that IR and extended-release formulations do not differ substantially with respect to efficacy and risk of harms. The evidence is mixed with respect to differences in adherence, indicating lower adherence for IR formulations. LIMITATIONS The lack of head-to-head comparisons for many drugs compromises our conclusions. Network meta-analyses have methodological limitations that need to be taken into consideration when interpreting findings. CONCLUSION Available evidence currently shows no clear differences between the two formulations and therefore we cannot recommend a first choice. However, if adherence or compliance with one medication is an issue, then clinicians and patients should consider the alternative medication. If adherence or costs are a problem with one formulation, consideration of the other formulation to provide an adequate treatment trial is reasonable.
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Affiliation(s)
- Barbara Nussbaumer
- Department for Evidence-Based Medicine and Clinical Epidemiology, Danube University Krems, Dr.-Karl-Dorrek Strasse 30, 3500, Krems, Austria,
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Gaynes BN, Lloyd SW, Lux L, Gartlehner G, Hansen RA, Brode S, Jonas DE, Swinson Evans T, Viswanathan M, Lohr KN. Repetitive transcranial magnetic stimulation for treatment-resistant depression: a systematic review and meta-analysis. J Clin Psychiatry 2014; 75:477-89; quiz 489. [PMID: 24922485 DOI: 10.4088/jcp.13r08815] [Citation(s) in RCA: 220] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Accepted: 02/11/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To evaluate the efficacy of repetitive transcranial magnetic stimulation (rTMS) in patients with major depressive disorder (MDD) and 2 or more prior antidepressant treatment failures (often referred to as treatment-resistant depression [TRD]). These patients are less likely to recover with medications alone and often consider nonpharmacologic treatments such as rTMS. DATA SOURCES We searched MEDLINE, EMBASE, the Cochrane Library, PsycINFO, and the International Pharmaceutical Abstracts for studies comparing rTMS with a sham-controlled treatment in TRD patients ages 18 years or older. STUDY SELECTION We included 18 good- or fair-quality TRD studies published from January 1, 1980, through March 20, 2013. DATA EXTRACTION We abstracted relevant data, assessed each study's internal validity, and graded strength of evidence for change in depressive severity, response rates, and remission rates. RESULTS rTMS was beneficial compared with sham for all outcomes. rTMS produced a greater decrease in depressive severity (high strength of evidence), averaging a clinically meaningful decrease on the Hamilton Depression Rating Scale (HDRS) of more than 4 points compared with sham (mean decrease = -4.53; 95% CI, -6.11 to -2.96). rTMS resulted in greater response rates (high strength of evidence); those receiving rTMS were more than 3 times as likely to respond as patients receiving sham (relative risk = 3.38; 95% CI, 2.24 to 5.10). Finally, rTMS was more likely to produce remission (moderate strength of evidence); patients receiving rTMS were more than 5 times as likely to achieve remission as those receiving sham (relative risk = 5.07; 95% CI, 2.50 to 10.30). Limited evidence and variable treatment parameters prevented conclusions about which specific treatment options are more effective than others. How long these benefits persist remains unclear. CONCLUSIONS For MDD patients with 2 or more antidepressant treatment failures, rTMS is a reasonable, effective consideration.
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Affiliation(s)
- Bradley N Gaynes
- Department of Psychiatry, CB #7160, 304 MacNider Hall, Room J, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7160
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Nussbaumer B, Morgan L, Reichenpfader U, Greenblatt A, Hanson R, Van Noord M, Lux L, Gaynes B, Gartlehner G. EPA-1042 – Immediate vs. extended release second-generation antidepressants in the treatment of major depressive disorder – a systematic review. Eur Psychiatry 2014. [DOI: 10.1016/s0924-9338(14)78330-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Zimmerman S, Anderson WL, Brode S, Jonas D, Lux L, Beeber AS, Watson LC, Viswanathan M, Lohr KN, Sloane PD. Systematic review: Effective characteristics of nursing homes and other residential long-term care settings for people with dementia. J Am Geriatr Soc 2013; 61:1399-409. [PMID: 23869936 DOI: 10.1111/jgs.12372] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES In response to the need for an evidence-based review of factors within long-term care settings that affect the quality of care, this review compared characteristics of nursing homes and other residential long-term care settings for people with dementia and their informal family caregivers with respect to health and psychosocial outcomes. DESIGN Databases were searched for literature published between 1990 and March 2012 that met review criteria, including that at least 80% of the subject population had dementia. RESULTS Fourteen articles meeting review criteria that were of at least fair quality were found: four prospective cohort studies, nine randomized controlled trials (RCTs), and one nonrandomized controlled trial. Overall, low or insufficient strength of evidence was found regarding the effect of most organizational characteristics, structures, and processes of care on health and psychosocial outcomes for people with dementia and no evidence for informal caregivers. Findings of moderate strength of evidence indicate that pleasant sensory stimulation reduces agitation for people with dementia. Also, although the strength of evidence is low, protocols for individualized care and to improve function result in better outcomes for these individuals. Finally, outcomes do not differ between nursing homes and residential care or assisted living settings for people with dementia except when medical care is indicated. CONCLUSION Given the paucity of high-quality studies in this area, additional research is needed to develop a sufficient evidence base to support consumer selection, practice, and policy regarding the best settings and characteristics of settings for residential long-term care of people with dementia.
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Affiliation(s)
- Sheryl Zimmerman
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, USA.
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West SL, Squiers LB, McCormack L, Southwell BG, Brouwer ES, Ashok M, Lux L, Boudewyns V, O'Donoghue A, Sullivan HW. Communicating quantitative risks and benefits in promotional prescription drug labeling or print advertising. Pharmacoepidemiol Drug Saf 2013; 22:447-58. [DOI: 10.1002/pds.3416] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2012] [Revised: 01/04/2013] [Accepted: 01/10/2013] [Indexed: 11/11/2022]
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Desai RJ, Hansen RA, Rao JK, Wilkins TM, Harden EA, Yuen A, Jonas DE, Roubey R, Jonas B, Gartlehner G, Lux L, Donahue KE. Mixed treatment comparison of the treatment discontinuations of biologic disease-modifying antirheumatic drugs in adults with rheumatoid arthritis. Ann Pharmacother 2012; 46:1491-505. [PMID: 23092868 DOI: 10.1345/aph.1r203] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Introduction of biologic disease-modifying antirheumatic drugs (DMARDs) has considerably changed treatment options for rheumatoid arthritis (RA) over the past decade. Very little information is available on comparative discontinuation rates of the biologics. OBJECTIVE To compare treatment discontinuations for 9 biologic DMARDs in adults with RA. METHODS We searched electronic databases through May 2012 to retrieve randomized controlled trials (RCTs) of patients with RA that compared biologic DMARDs with placebo or another biologic DMARD. The primary outcome was treatment discontinuation during the blinded phase of the trials, measured as overall withdrawals, withdrawals resulting from lack of efficacy, and withdrawals resulting from adverse events. Random-effects meta-analysis estimated the effect size for individual agents, and adjusted indirect comparisons were made between biologics using mixed treatment comparisons (MTC) meta-analysis. RESULTS Forty-four trials were included in the analysis. In comparison with placebo, biologics were less likely to be withdrawn because of lack of efficacy (OR 0.22, 95% CI 0.17 to 0.27) and more likely to be withdrawn because of an adverse event (OR 1.41, 95% CI 1.16 to 1.70). Based on the MTC, certolizumab had the most favorable overall withdrawal profile, followed by etanercept and rituximab. Certolizumab had lower relative withdrawal rates resulting from lack of efficacy than adalimumab, anakinra, and infliximab. Anakinra had higher relative withdrawal rates resulting from lack of efficacy than most other biologics. Certolizumab and infliximab had more, while etanercept had fewer, withdrawals because of adverse events than most other drugs. CONCLUSIONS Based on MTC using data from RCTs, differences in discontinuation rates were observed, generally favoring certolizumab, etanercept, and rituximab over other biologic DMARDs. These potential differences need to be further explored in head-to-head trials or well-conducted observational studies.
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Affiliation(s)
- Rishi J Desai
- Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
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Viswanathan M, Lux L, Lohr KN, Evans TS, Smith LR, Woodell C, Mansfield C, Darcy N, Ohadike YU, Lesch JK, Malveaux FJ. Translating evidence-based interventions into practice: the design and development of the Merck Childhood Asthma Network, Inc. (MCAN). Health Promot Pract 2012; 12:9S-19S. [PMID: 22068366 DOI: 10.1177/1524839911412594] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Pediatric asthma is a multifactorial disease, requiring complex, interrelated interventions addressing children, families, schools, and communities. The Merck Childhood Asthma Network, Inc. (MCAN) is a nonprofit organization that provides support to translate evidence-based interventions from research to practice. MCAN developed the rationale and vision for the program through a phased approach, including an extensive literature review, stakeholder engagement, and evaluation of funding gaps. The analysis pointed to the need to identify pediatric asthma interventions implemented in urban U.S. settings that have demonstrated efficacy and materials for replication and to translate the interventions into wider practice. In addition to this overall MCAN objective, specific goals included service and system integration through linkages among health care providers, schools, community-based organizations, patients, parents, and other caregivers. MCAN selected sites based on demonstrated ability to implement effective interventions and to address multiple contexts of pediatric asthma prevention and management. Selected MCAN program sites were mature institutions or organizations with significant infrastructure, existing funding, and the ability to provide services without requiring a lengthy planning period. Program sites were located in communities with high asthma morbidity and intended to integrate new elements into existing programs to create comprehensive care approaches.
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Gartlehner G, Hansen RA, Morgan LC, Thaler K, Lux L, Van Noord M, Mager U, Thieda P, Gaynes BN, Wilkins T, Strobelberger M, Lloyd S, Reichenpfader U, Lohr KN. Comparative benefits and harms of second-generation antidepressants for treating major depressive disorder: an updated meta-analysis. Ann Intern Med 2011; 155:772-85. [PMID: 22147715 DOI: 10.7326/0003-4819-155-11-201112060-00009] [Citation(s) in RCA: 226] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Second-generation antidepressants dominate the management of major depressive disorder (MDD), but evidence on the comparative benefits and harms of these agents is contradictory. PURPOSE To compare the benefits and harms of second-generation antidepressants for treating MDD in adults. DATA SOURCES English-language studies from PubMed, Embase, the Cochrane Library, PsycINFO, and International Pharmaceutical Abstracts from 1980 to August 2011 and reference lists of pertinent review articles and gray literature. STUDY SELECTION 2 independent reviewers identified randomized trials of at least 6 weeks' duration to evaluate efficacy and observational studies with at least 1000 participants to assess harm. DATA EXTRACTION Reviewers abstracted data about study design and conduct, participants, and interventions and outcomes and rated study quality. A senior reviewer checked and confirmed extracted data and quality ratings. DATA SYNTHESIS Meta-analyses and mixed-treatment comparisons of response to treatment and weighted mean differences were conducted on specific scales to rate depression. On the basis of 234 studies, no clinically relevant differences in efficacy or effectiveness were detected for the treatment of acute, continuation, and maintenance phases of MDD. No differences in efficacy were seen in patients with accompanying symptoms or in subgroups based on age, sex, ethnicity, or comorbid conditions. Individual drugs differed in onset of action, adverse events, and some measures of health-related quality of life. LIMITATIONS Most trials were conducted in highly selected populations. Publication bias might affect the estimates of some comparisons. Mixed-treatment comparisons cannot conclusively exclude differences in efficacy. Evidence within subgroups was limited. CONCLUSION Current evidence does not warrant recommending a particular second-generation antidepressant on the basis of differences in efficacy. Differences in onset of action and adverse events may be considered when choosing a medication. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality.
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Tsertsvadze A, Maglione M, Chou R, Garritty C, Coleman C, Lux L, Bass E, Balshem H, Moher D. Updating comparative effectiveness reviews: current efforts in AHRQ's Effective Health Care Program. J Clin Epidemiol 2011; 64:1208-15. [PMID: 21684114 DOI: 10.1016/j.jclinepi.2011.03.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2009] [Revised: 02/24/2011] [Accepted: 03/13/2011] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To review the current knowledge and efforts on updating systematic reviews (SRs) as applied to comparative effectiveness reviews (CERs). STUDY DESIGN AND SETTING This article outlines considerations for updating CERs by including a definition of the updating process, describing issues around assessing whether to update, and providing general guidelines for the update process. Key points to consider include (1) identifying when to update CERs, (2) how to update CERs, and (3) how to present, report, and interpret updated results in CERs. RESULTS Currently, there is little information about what proportion of SRs needs updating. Similarly, there is no consensus on when to initiate updating and how best to carry it out. CONCLUSION CERs need to be regularly updated as new evidence is produced. Lack of attention to updating may lead to outdated and sometimes misleading conclusions that compromise health care and policy decisions. The article outlines several specific goals for future research, one of them being the development of efficient guideline for updating CERs applicable across evidence-based practice centers.
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Affiliation(s)
- Alexander Tsertsvadze
- University of Ottawa Evidence-Based Practice Center, Clinical Epidemiology Methods Centre, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada K1H 8L6.
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Van Noord M, Gartlehner G, Hansen R, Morgan L, Thaler K, Lux L, Mager U, Gaynes B, Thieda P, Strobelberger M, Lloyd S, Reichenpfader U, Lohr K. Immediate-release and extended-release formulations of second-generation antidepressants for the treatment of major depressive disorder in adults. Eur Psychiatry 2011. [DOI: 10.1016/s0924-9338(11)72994-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
IntroductionExtended-release formulations of antidepressants have been marketed as a strategy to increase patient adherence. Changes in the formulation of drugs, however, could be related to changes in efficacy and tolerability. Among second-generation antidepressants, bupropion, fluoxetine, mirtazapine, paroxetine, and venlafaxine are available in immediate- and extended-release formulations.ObjectivesTo compare the efficacy, tolerability, and adherence of immediate- versus extended-release formulations of second-generation antidepressants for the treatment of major depressive disorder (MDD) in adults.AimTo provide an evidence base for clinicians when choosing immediate- or extended-release formulations of antidepressants for the treatment of MDD.MethodsWe conducted a comparative effectiveness review for the U.S. Agency for Healthcare Research and Quality searching PubMed, EMBASE, The Cochrane Library, and the International Pharmaceutical Abstracts up to May 2010. Two people independently reviewed the literature, abstracted data, and rated the risk of bias.ResultsSix RCTs and one observational study provided evidence about the comparative efficacy, tolerability, and adherence of bupropion SR (sustained release) versus bupropion XL (extended release), fluoxetine daily vs. fluoxetine weekly, paroxetine IR (immediate release) versus paroxetine CR (continuous release), and venlafaxine IR versus venlafaxine XR (extended release). Overall, no substantial differences in efficacy and safety could be detected. Open-label and observational evidence indicated better adherence for bupropion XL and fluoxetine weekly than for immediate-release medications. No differences in adherence could be detected between paroxetine IR and paroxetine CR.ConclusionsOur findings indicate similar efficacy and tolerability between immediate- and extended-release formulations. Whether extended-release formulations lead to better adherence remains unclear.
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Abstract
BACKGROUND While smoking cessation interventions have been shown to work, questions remain about how to increase their efficacy. PURPOSE To examine strategies for effective tobacco treatment in adults and special populations. DATA SOURCES MEDLINE, Cumulative Index to Nursing and Applied Health (CINAHL), Cochrane Library, Cochrane Clinical Trials Register, Psychological Abstracts, and Sociological Abstracts (1 January 1980 to 10 June 2005). STUDY SELECTION Systematic reviews; randomized, controlled trials; and observational studies. DATA EXTRACTION Two reviewers independently abstracted data on study design, population, sample size, treatment, outcomes, and quality. DATA SYNTHESIS Findings from systematic reviews were summarized and compared with findings from original research published beyond date ranges included in the reviews. Strength of evidence was used to assess the body of evidence. Our review included studies evaluating the efficacy of cessation strategies, such as self-help, counseling, single pharmaceutical agents, combined pharmacotherapies, and pharmacotherapies combined with psychological counseling. Research findings consistent with previous reviews show that self-help strategies alone are ineffective, but counseling and pharmacotherapy used either alone or in combination can improve rates of success with quit attempts. Two studies of self-help materials reported discrepancies across effects. Five studies provided mixed results for counseling interventions. Fourteen studies provided sufficient evidence of the efficacy of single pharmacotherapy, combined pharmacotherapy, and psychological interventions either with or without pharmacotherapy. Few studies focused on ways to reach or treat special populations. Three studies with hospitalized patients had findings consistent with a previous review showing no strong evidence that clinical diagnosis affected the likelihood of quitting. New evidence was insufficient to address the effectiveness of interventions for persons with coexisting psychiatric conditions and substance abuse problems. LIMITATIONS Previous systematic reviews variably cover the range of issues we addressed. More recent studies do not fill all gaps, especially those for persons with coexisting disease. CONCLUSIONS Although self-help strategies alone marginally affect quit rates, individual and combined pharmacotherapies and counseling either alone or in combination can significantly increase cessation. Using effective smoking treatments is strongly encouraged for all populations, especially those with high and heavy rates of smoking, such as psychiatric and substance abuse populations.
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Affiliation(s)
- Leah Ranney
- Cecil G. Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina 27599, USA
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Visco AG, Viswanathan M, Lohr KN, Wechter ME, Gartlehner G, Wu JM, Palmieri R, Funk MJ, Lux L, Swinson T, Hartmann K. Cesarean Delivery on Maternal Request. Obstet Gynecol 2006; 108:1517-29. [PMID: 17138788 DOI: 10.1097/01.aog.0000241092.79282.87] [Citation(s) in RCA: 116] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To review systematically the evidence about maternal and infant outcomes of cesarean delivery on maternal request and planned vaginal delivery. DATA SOURCES We searched MEDLINE, Cochrane Collaboration resources, and Embase and identified 1,406 articles through dual review using a priori inclusion criteria. METHODS OF STUDY SELECTION We included English language studies published from 1990 to June 2005 that compared the key reference group (cesarean delivery on maternal request or proxies) and planned vaginal delivery. TABULATION, INTEGRATION, AND RESULTS We identified 54 articles for maternal and infant outcomes. Virtually no studies exist on cesarean delivery on maternal request, so the knowledge base rests on indirect evidence from proxies with unique and significant limitations. Most studies compared outcomes by actual routes of delivery, resulting in variable relevance to planned routes of delivery. Primary cesarean delivery on maternal request and planned vaginal delivery likely differ with respect to individual outcomes; for instance, risks of urinary incontinence and maternal hemorrhage were lower with planned cesarean, whereas the risk of neonatal respiratory morbidity was higher and maternal length of stay was longer with planned cesarean delivery. However, our comprehensive assessment, across many outcomes, suggests no major differences between primary cesarean delivery on maternal request and planned vaginal delivery, but the evidence is too weak to conclude definitively that differences are completely absent. If a woman chooses to have a cesarean delivery in her first delivery, she is more likely to have subsequent deliveries by cesarean. With increasing numbers of cesarean delivery, risks occur with increasing frequency. CONCLUSION The evidence is significantly limited by its minimal relevance to primary cesarean delivery on maternal request. Future research requires developing consensus about terminology, creating a minimum data set for cesarean delivery on maternal request, improving study design and statistical analyses, attending to major outcomes and their special measurement issues, assessing both short- and long-term outcomes with better measurement strategies, dealing better with confounders, and considering the value or utility of different outcomes.
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Affiliation(s)
- Anthony G Visco
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina 27599, USA.
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Ranney L, Melvin C, Lux L, McClain E, Morgan L, Lohr KN. Tobacco use: prevention, cessation, and control. Evid Rep Technol Assess (Full Rep) 2006:1-120. [PMID: 17764211 PMCID: PMC4781119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
OBJECTIVES The RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center (RTI-UNC EPC) systematically reviewed the evidence on (a) the effectiveness of community- and population-based interventions to prevent tobacco use and to increase consumer demand for and implementation of effective cessation interventions; (b) the impacts of smokeless tobacco marketing on smoking, use of those products, and population harm; and (c) the directions for future research. DATA SOURCES We searched MEDLINE, Cumulative Index to Nursing and Applied Health (CINAHL), Cochrane libraries, Cochrane Clinical Trials Register, Psychological Abstracts, and Sociological Abstracts from January 1980 through June 10, 2005. We included English-language randomized controlled trials, other trials, and observational studies, with sample size and follow-up restrictions. We used 13 Cochrane Collaboration systematic reviews, 5 prior systematic reviews, and 2 meta-analyses as the foundation for this report. REVIEW METHODS Trained reviewers abstracted detailed data from included articles into evidence tables and completed quality assessments; other senior reviewers confirmed accuracy and resolved disagreements. RESULTS We identified 1,288 unique abstracts; 642 did not meet inclusion criteria, 156 overlapped with prior reviews, and 2 were not published articles. Of 488 full-text articles retrieved and reviewed, we excluded 298 for several reasons, marked 88 as background, and retained 102. Evidence (consistent with previous reviews) showed that (a) school-based prevention interventions have short-term (but not long-term) effects on adolescents; (b) multicomponent approaches, including telephone counseling, increase the number of users who attempt to quit; (c) self-help strategies alone are ineffective, but counseling and pharmacotherapy used either alone or in combination can improve success rates of quit attempts; and (d) provider training and academic detailing improve provider delivery of cessation treatments, but evidence is insufficient to show that these approaches yield higher quit rates. New evidence was insufficient to address the following: (a) effectiveness of population-based prevention interventions; (b) effectiveness of provider-based interventions to reduce tobacco initiation; (c) effectiveness of community- and provider-based interventions to increase use of proven cessation strategies; (d) effectiveness of marketing campaigns to switch tobacco users from smoking to smokeless tobacco products; and (e) effectiveness of interventions in populations with comorbidities and risk behaviors (e.g., depression, substance and alcohol abuse). No evidence was available on the way in which smokeless tobacco product marketing affects population harm. CONCLUSIONS The evidence base has notable gaps and numerous study deficiencies. We found little information to address some of the issues that previous authoritative reviews had not covered, some information to substantiate earlier conclusions and recommendations from those reviews, and no evidence that would overturn any previous recommendations.
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Viswanathan M, Visco AG, Hartmann K, Wechter ME, Gartlehner G, Wu JM, Palmieri R, Funk MJ, Lux L, Swinson T, Lohr KN. Cesarean delivery on maternal request. Evid Rep Technol Assess (Full Rep) 2006:1-138. [PMID: 17627329 PMCID: PMC4781381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
OBJECTIVES The RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center (RTI-UNC EPC) systematically reviewed the evidence on the trend and incidence of cesarean delivery (CD) in the United States and in other developed countries, maternal and infant outcomes of cesarean delivery on maternal request (CDMR) compared with planned vaginal delivery (PVD), factors affecting the magnitude of the benefits and harms of CDMR, and future research directions. DATA SOURCES We searched MEDLINE, Cochrane Collaboration resources, and Embase and identified 1,406 articles to examine against a priori inclusion criteria. We included studies published from 1990 to the present, written in English. Studies had to include comparison between the key reference group (CDMR or proxies) and PVD. REVIEW METHODS A primary reviewer abstracted detailed data on key variables from included articles; a second senior reviewer confirmed accuracy. RESULTS We identified 13 articles for trends and incidence of CD, 54 for maternal and infant outcomes, and 5 on modifiers of CDMR. The incidence of CDMR appears to be increasing. However, accurately assessing either its true incidence or trends over time is difficult because currently CDMR is neither a well-recognized clinical entity nor an accurately reported indication for diagnostic coding or reimbursement. Virtually no studies exist on CDMR, so the knowledge base rests chiefly on indirect evidence from proxies possessing unique and significant limitations. Furthermore, most studies compared outcomes by actual routes of delivery, resulting in great uncertainty as to their relevance to planned routes of delivery. Primary CDMR and planned vaginal delivery likely do differ with respect to individual outcomes for either mothers or infants. However, our comprehensive assessment, across many different outcomes, suggests that no major differences exist between primary CDMR and planned vaginal delivery, but the evidence is too weak to conclude definitively that differences are completely absent. Given the limited data available, we cannot draw definitive conclusions about factors that might influence outcomes of planned CDMR versus PVD. CONCLUSIONS The evidence is significantly limited by its minimal relevance to primary CDMR. Future research requires developing consensus about terminology for both delivery routes and outcomes; creating a minimum data set of information about CDMR; improving study design and statistical analyses; attending to major outcomes and their special measurement issues; assessing both short- and long-term outcomes with better measurement strategies; dealing better with confounders; and considering the value or utility of different outcomes.
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Abstract
BACKGROUND Chronic periodontitis affects many adults in the United States, some severely enough to threaten tooth loss. Of particular clinical importance is whether scaling and root planing (SRP) accompanied by a local adjunctive therapeutic agent improves outcomes over time compared to SRP alone. The adjunctive therapeutic agents investigated include: tetracycline, minocycline, metronidazole, a group of other antibiotics, chlorhexidine, and a group of antimicrobials. Primary outcomes considered are reductions in probing depth (PD) and gains in clinical attachment level (CAL). METHODS RTI-UNC Evidence-Based Practice Center staff searched MEDLINE (1966 through December 2002) and EMBASE (through February 2002) to identify clinical trials published in English that 1) involved adults with chronic periodontitis but no serious comorbidities; 2) tested one or more chemical antimicrobial agents as an adjunct to SRP alone or with a placebo; 3) had a concurrent control group that received the same SRP as the treatment group; 4) reported outcomes for specified, fixed time periods; and 5) if multiple antimicrobials were tested, reported outcomes for each agent separately. We performed qualitative analyses and meta-analyses of PD and CAL effect sizes when the necessary data were available from at least three studies at 6-month follow-up. RESULTS Among the locally administered adjunctive antimicrobials, the most positive results occurred for tetracycline, minocycline, metronidazole, and chlorhexidine. Adjunctive local therapy generally reduced PD levels. Differences between treatment and SRP-only groups in the baseline-to-follow-up period typically favored treatment groups but usually only modestly (e.g., from about 0.1 mm to nearly 0.5 mm) even when the differences were statistically significant. Effects for CAL gains were smaller and statistical significance less common. The marginal improvements in PD and CAL were a fraction of the improvement from SRP alone. CONCLUSIONS Whether such improvements, even if statistically significant, are clinically meaningful remains a question. A substantial agenda of future research to address this and other issues (e.g., costs, patient-oriented outcomes) is suggested.
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Affiliation(s)
- Arthur J Bonito
- Program on Health Care Organization, Delivery and Access, Health, Social, and Economic Research, Research Triangle Institute International, Research Triangle Park, NC 27709-2194, USA.
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Viswanathan M, Hartmann K, Palmieri R, Lux L, Swinson T, Lohr KN, Gartlehner G, Thorp J. The use of episiotomy in obstetrical care: a systematic review. Evid Rep Technol Assess (Summ) 2005:1-8. [PMID: 15910014 PMCID: PMC4780926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
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Viswanathan M, Ammerman A, Eng E, Garlehner G, Lohr KN, Griffith D, Rhodes S, Samuel-Hodge C, Maty S, Lux L, Webb L, Sutton SF, Swinson T, Jackman A, Whitener L. Community-based participatory research: assessing the evidence. Evid Rep Technol Assess (Summ) 2004:1-8. [PMID: 15460504 PMCID: PMC4780908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
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Bonito AJ, Lohr KN, Lux L, Sutton S, Jackman A, Whitener L, Evensen C. Effectiveness of antimicrobial adjuncts to scaling and root-planing therapy for periodontitis. Evid Rep Technol Assess (Summ) 2004:1-4. [PMID: 15164672 PMCID: PMC4780917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
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Berkman ND, Dewalt DA, Pignone MP, Sheridan SL, Lohr KN, Lux L, Sutton SF, Swinson T, Bonito AJ. Literacy and health outcomes. Evid Rep Technol Assess (Summ) 2004:1-8. [PMID: 15819598 PMCID: PMC4781151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
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McTigue KM, Harris R, Hemphill B, Lux L, Sutton S, Bunton AJ, Lohr KN. Screening and interventions for obesity in adults: summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2003; 139:933-49. [PMID: 14644897 DOI: 10.7326/0003-4819-139-11-200312020-00013] [Citation(s) in RCA: 363] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Obesity poses a considerable and growing health burden. This review examines evidence for screening and treating obesity in adults. DATA SOURCES MEDLINE and Cochrane Library (January 1994 through February 2003). STUDY SELECTION Systematic reviews; randomized, controlled trials; and observational studies of obesity's health outcomes or efficacy of obesity treatment. DATA EXTRACTION Two reviewers independently abstracted data on study design, sample, sample size, treatment, outcomes, and quality. DATA SYNTHESIS No trials evaluated mass screening for obesity, so the authors evaluated indirect evidence for efficacy. Pharmacotherapy or counseling interventions produced modest (generally 3 to 5 kg) weight loss over at least 6 or 12 months, respectively. Counseling was most effective when intensive and combined with behavioral therapy. Maintenance strategies helped retain weight loss. Selected surgical patients lost substantial weight (10 to 159 kg over 1 to 5 years). Weight reduction improved blood pressure, lipid levels, and glucose metabolism and decreased diabetes incidence. The internal validity of the treatment trials was fair to good, and external validity was limited by the minimal ethnic or gender diversity of volunteer participants. No data evaluated counseling harms. Primary adverse drug effects included hypertension with sibutramine (mean increase, 0 mm Hg to 3.5 mm Hg) and gastrointestinal distress with orlistat (1% to 37% of patients). Fewer than 1% (pooled samples) of surgical patients died; up to 25% needed surgery again over 5 years. CONCLUSIONS Counseling and pharmacotherapy can promote modest sustained weight loss, improving clinical outcomes. Pharmacotherapy appears safe in the short term; long-term safety has not been as strongly established. In selected patients, surgery promotes large amounts of weight loss with rare but sometimes severe complications.
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Kizakevich PN, Lux L, Duncan S, Guinn C, McCartrey ML. Virtual simulated patients for bioterrorism preparedness training. Stud Health Technol Inform 2003; 94:165-7. [PMID: 15455883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Affiliation(s)
- Paul N Kizakevich
- RTI International, 3040 Cornwallis Road, Research Triangle Park, NC 27709, USA
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West S, King V, Carey TS, Lohr KN, McKoy N, Sutton SF, Lux L. Systems to rate the strength of scientific evidence. Evid Rep Technol Assess (Summ) 2002:1-11. [PMID: 11979732 PMCID: PMC4781591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/18/2023]
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Bürkmann I, Lux L. [Pre- and postoperative results of spirography and blood gas analysis in patients with atrial septal defect or mitral stenosis]. Z Gesamte Inn Med 1985; 40:707-10. [PMID: 4096054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
In patients with atrial septum defect and mitral stenosis, respectively, the ventilation and blood gas parameters were compared before and after cardiac operation. In general postoperatively no reversibility of preoperatively proved pulmonary functional disturbances could be established. Only in individual cases a discrete improvement of some of the functional indicators could be observed. Therefore, the operative intervention on the heart should be performed possibly before the onset of irreversible pulmonary structural changes.
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