Tools for the Diagnosis of ADHD in Children and Adolescents: A Systematic Review

CONTEXT

Correct diagnosis is essential for the appropriate clinical management of attention-deficit/hyperactivity disorder (ADHD) in children and adolescents.

OBJECTIVE

This systematic review provides an overview of the available diagnostic tools.

DATA SOURCES

We identified diagnostic accuracy studies in 12 databases published from 1980 through June 2023.

STUDY SELECTION

Any ADHD tool evaluation for the diagnosis of ADHD, requiring a reference standard of a clinical diagnosis by a mental health specialist.

DATA EXTRACTION

Data were abstracted and critically appraised by 1 reviewer and checked by a methodologist. Strength of evidence and applicability assessments followed Evidence-based Practice Center standards.

RESULTS

In total, 231 studies met eligibility criteria. Studies evaluated parental ratings, teacher ratings, youth self-reports, clinician tools, neuropsychological tests, biospecimen, EEG, and neuroimaging. Multiple tools showed promising diagnostic performance, but estimates varied considerably across studies, with a generally low strength of evidence. Performance depended on whether ADHD youth were being differentiated from neurotypically developing children or from clinically referred children.

LIMITATIONS

Studies used different components of available tools and did not report sufficient data for meta-analytic models.

CONCLUSIONS

A valid and reliable diagnosis of ADHD requires the judgment of a clinician who is experienced in the evaluation of youth with and without ADHD, along with the aid of standardized rating scales and input from multiple informants across multiple settings, including parents, teachers, and youth themselves.

Treatments for ADHD in Children and Adolescents: A Systematic Review

CONTEXT

Effective treatment of attention-deficit/hyperactivity disorder (ADHD) is essential to improving youth outcomes.

OBJECTIVES

This systematic review provides an overview of the available treatment options.

DATA SOURCES

We identified controlled treatment evaluations in 12 databases published from 1980 to June 2023; treatments were not restricted by intervention content.

STUDY SELECTION

Studies in children and adolescents with clinically diagnosed ADHD, reporting patient health and psychosocial outcomes, were eligible. Publications were screened by trained reviewers, supported by machine learning.

DATA EXTRACTION

Data were abstracted and critically appraised by 1 reviewer and checked by a methodologist. Data were pooled using random-effects models. Strength of evidence and applicability assessments followed Evidence-based Practice Center standards.

RESULTS

In total, 312 studies reported in 540 publications were included. We grouped evidence for medication, psychosocial interventions, parent support, nutrition and supplements, neurofeedback, neurostimulation, physical exercise, complementary medicine, school interventions, and provider approaches. Several treatments improved ADHD symptoms. Medications had the strongest evidence base for improving outcomes, including disruptive behaviors and broadband measures, but were associated with adverse events.

LIMITATIONS

We found limited evidence of studies comparing alternative treatments directly and indirect analyses identified few systematic differences across stimulants and nonstimulants. Identified combination of medication with youth-directed psychosocial interventions did not systematically produce better results than monotherapy, though few combinations have been evaluated.

CONCLUSIONS

A growing number of treatments are available that improve ADHD symptoms and other outcomes, in particular for school-aged youth. Medication therapies remain important treatment options but are associated with adverse events.

Assessment of intracardiac flow dynamics for the evaluation of patients with different ventricular geometry

Background

Over the last decades growing evidence have demonstrated the promising role of intracardiac flow dynamic analysis in evaluating cardiac performance. Diastolic forces contribute to the formation of vortices, complex structures capable of kinetic energy storage and responsible of a smoother transition of blood from left ventricular (LV) inlet to outlet. Change in shape and location of these structures has been related with cardiovascular disease and prognosis.

Purpose

To investigate quantitative changes in vortices parameters in patients with different ventricular geometry.

Methods

We enrolled 72 consecutive patients (age 66±11 years, 49 male, 68%) with LV concentric hypertrophy (CH, n=15), eccentric hypertrophy (EH, n=13), concentric remodeling (CR, n=15) and normal LV geometry (CTRL, n=29). Each patient underwent a complete echocardiographic examination and a non-invasive intracardiac fluid dynamic analysis by Color Vector Flow Mapping. A 3-chamber apical view with a frame rate between 22 and 25 Hz has been acquired and subsequently analyzed offline by a semi-automatic software obtaining the following parameters: vortex area (VA) (the ratio between the total vortex area and the left ventricular (LV) area); vortex length (VL) (the longitudinal length of the vortex relative to the total LV length; vortex depth (VD) (the distance of the vortex center from the LV base relative to the total LV long axis). Bland Altman Plot has been used to assess intra and inter-observer variability.

Results

Mean VD was higher in CR, CH and EH compared to CTRL (p=0.013, p=0.001 and p=0.022, respectively). Moreover, CH showed higher VL (p=0.006) and larger VA (p=0.012) compared to CTRL. A similar trend was noticed in EH patients, despite did not reach statistical significance (p=0.21 and p=0.07 for VA and VL respectively). No significative differences in vortices parameters have been observed between CH and EH.

Conclusion(s)

This is the first study providing quantitative echocardiographic parameters of vortex location and morphology in different LV geometries. Higher values of VD were found in CR, CH and EG. Quantitative intra dynamic fluid assessment was feasible and reliable in the whole population and could provide additional information to the standard echocardiographic examination.

Funding Acknowledgement

Type of funding sources: None.

Assessment of intracardiac flow dynamics for the evaluation of patients with aortic stenosis

Background

Assessment of intracardiac flows and turbulence has acquired rising significance in the past few years, due to the development and introduction of technologies for non-invasive cardiovascular imaging. Recent studies have shown that alterations in intracardiac fluid dynamics can be helpful to identify abnormalities in cardiac function.

Purpose

This study investigates the additional information provided by the quantitative assessment of intracardiac flow dynamics for the evaluation of patients with aortic stenosis (AS), by using an advanced echocardiography vortex-based approach.

Methods

Sixty-one patients with severe AS (33 females) and 38 healthy sex- and BSA-matched controls (CTRL) (15 females) were prospectively included and underwent echocardiographic assessment of intracardiac flow dynamics. Echocardiographic measurements were performed on apical three chamber views. The HyperDoppler software adapted to the echo-scanner without contrast injection was used to assess intracardiac vortex properties. The following parameters were obtained: vortex area (VA) (the ratio between the total vortex area and the left ventricular (LV) area); vortex length (VL) (the longitudinal length of the vortex relative to the total LV length; vortex depth (VD) (the distance of the vortex center from the LV base relative to the total LV long axis). Inter-rater variability was measured using intraclass correlation coefficients (ICCs) between two independent operators.

Results

Patients with severe AS (mean gradient: 47,5±13,9 mmHg; aortic valve area: 0.7±0.2 cm2; ejection fraction: 53±7%) had increased LV wall thickness (p<0.001) and mass index (p<0.001) compared with controls. Greater indexed left atrial volume (p<0.001), E/e' (p<0.001) and trans-tricuspid gradient (p<0.001) were also observed in the AS group. The assessment of VA, VL and VD was feasible in the whole population. Their calculation was reliable, as ICCs were very good for VA (0.878, p=0.033), VL (0.960, p=0.004) and VD (0,905, p=0.021). Mean VA was significantly larger in patients with severe aortic stenosis compared with CTRL (p=0.033). VL and VD (p=0.026 and p>0.001, respectively) were significantly higher in AS patients compared with CTRL. Among those who underwent TAVR, we observed a significant difference in the delta values of VA and VL pre-postTAVR in patients with and without significant paravalvular leak (p<0.05).

Conclusions

The newly defined VA, VL and VD, quantitative indices of vortical flow, were significantly increased in the LV cavity of patients with severe AS compared to normal subjects. These indices, whose measurement was feasible and reliable, might provide complementary information to standard echocardiography, useful for the further diagnostic and prognostic characterization of the heterogeneous population of patients with severe AS.

Funding Acknowledgement

Type of funding sources: None.

Safety of vaccines used for routine immunization in the United States: An updated systematic review and meta-analysis

BACKGROUND

Understanding the safety of vaccines is critical to inform decisions about vaccination. Our objective was to conduct a systematic review of the safety of vaccines recommended for children, adults, and pregnant women in the United States.

METHODS

We searched the literature in November 2020 to update a 2014 Agency for Healthcare Research and Quality review by integrating newly available data. Studies of vaccines that used a comparator and reported the presence or absence of key adverse events were eligible. Adhering to Evidence-based Practice Center methodology, we assessed the strength of evidence (SoE) for all evidence statements. The systematic review is registered in PROSPERO (CRD42020180089).

RESULTS

Of 56,603 reviewed citations, 338 studies reported in 518 publications met inclusion criteria. For children, SoE was high for no increased risk of autism following measles, mumps, and rubella (MMR) vaccine. SoE was high for increased risk of febrile seizures with MMR. There was no evidence of increased risk of  intussusception with rotavirus vaccine at the latest follow-up (moderate SoE), nor of diabetes (high SoE). There was no evidence of increased risk or insufficient evidence for key adverse events for newer vaccines such as 9-valent human papillomavirus and meningococcal B vaccines. For adults, there was no evidence of increased risk (varied SoE) or insufficient evidence for key adverse events for the new adjuvanted inactivated influenza vaccine and recombinant adjuvanted zoster vaccine. We found no evidence of increased risk (varied SoE) for key adverse events among pregnant women following tetanus, diphtheria, and acellular pertussis vaccine, including stillbirth (moderate SoE).

CONCLUSIONS

Across a large body of research we found few associations of vaccines and serious key adverse events; however, rare events are challenging to study. Any adverse events should be weighed against the protective benefits that vaccines provide.

Static cold storage compared with normothermic machine perfusion of the liver and effect on ischaemic-type biliary lesions after transplantation: a propensity score-matched study

BACKGROUND

Given the susceptibility of organs to ischaemic injury, alternative preservation methods to static cold storage (SCS), such as normothermic machine perfusion (NMP) are emerging. The aim of this study was to perform a comparison between NMP and SCS in liver transplantation with particular attention to bile duct lesions.

METHODS

The outcomes of 59 consecutive NMP-preserved donor livers were compared in a 1 : 1 propensity score-matched fashion to SCS control livers. Postoperative complications, patient survival, graft survival and bile duct lesions were analysed.

RESULTS

While patients were matched for cold ischaemia time, the total preservation time was significantly longer in the NMP group (21 h versus 7 h, P < 0.001). Patient and graft survival rates at 1 year were 81 versus 82 per cent (P = 0.347) and 81 versus 79 per cent (P = 0.784) in the NMP and SCS groups, respectively. The postoperative complication rate was comparable (P = 0.086); 37 per cent NMP versus 34 per cent SCS patients had a Clavien-Dindo grade IIIb or above complication. There was no difference in early (30 days or less) (NMP 22 versus SCS 19 per cent, P = 0.647) and late (more than 30 days) (NMP 27 versus SCS 36 per cent, P = 0.321) biliary complications. However, NMP-preserved livers developed significantly fewer ischaemic-type bile duct lesions (NMP 3 versus SCS 14 per cent, P = 0.047).

CONCLUSION

The use of NMP allowed for a significantly prolonged organ preservation with a lower rate of observed ischaemic-type bile duct lesions.

Genetic Variation and Hot Flashes: A Systematic Review

CONTEXT

Approximately 70% of women report experiencing vasomotor symptoms (VMS, hot flashes and/or night sweats). The etiology of VMS is not clearly understood but may include genetic factors.

EVIDENCE ACQUISITION

We searched PubMed and Embase in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance. We included studies on associations between genetic variation and VMS. We excluded studies focused on medication interventions or prevention or treatment of breast cancer.

EVIDENCE SYNTHESIS

Of 202 unique citations, 18 citations met the inclusion criteria. Study sample sizes ranged from 51 to 17 695. Eleven of the 18 studies had fewer than 500 participants; 2 studies had 1000 or more. Overall, statistically significant associations with VMS were found for variants in 14 of the 26 genes assessed in candidate gene studies. The cytochrome P450 family 1 subfamily A member 1 (CYP1B1) gene was the focus of the largest number (n = 7) of studies, but strength and statistical significance of associations of CYP1B1 variants with VMS were inconsistent. A genome-wide association study reported statistically significant associations between 14 single-nucleotide variants in the tachykinin receptor 3 gene and VMS. Heterogeneity across trials regarding VMS measurement methods and effect measures precluded quantitative meta-analysis; there were few studies of each specific genetic variant.

CONCLUSIONS

Genetic variants are associated with VMS. The associations are not limited to variations in sex-steroid metabolism genes. However, studies were few and future studies are needed to confirm and extend these findings.

Assessment of the Clinical Impact of a Liver-Specific, BCAA-Enriched Diet in Major Liver Surgery

BACKGROUND

The relationship between nutrition and liver disease is relevant for the outcome after surgery. Patients with liver cirrhosis characteristically show protein-energy malnutrition with decreased levels of branched-chain amino acids (BCAA) and increased levels of aromatic amino acids.

MATERIALS AND METHODS

We conducted a prospective controlled clinical trial including 57 patients after liver transplantation or major liver resection surgery in order to test the effect of early postoperative nutrition on the outcome and nutrition profile of these patients. The test group received a dietetic program composed of ingredients naturally rich in BCAA (BCAA group), and the control group received standard hospital meals. Patient survival, liver function tests, subjective well-being, and a nutritional status including amino acid profiles were analyzed immediately and 14 days after major liver surgery (secondary end points). General health and well-being were assessed using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (primary end point).

RESULTS

In-depth analysis of amino acid profiles was performed for patients undergoing liver resection (n = 21) and liver transplantation (n = 36). Interestingly, amino acid profiles did not correlate with body mass index or the Model for End-Stage Liver Disease score. Patients scheduled for liver transplantation showed significantly lower levels of BCAA pretransplant compared to patients undergoing liver resection. Patients in the liver resection subgroup were more likely to benefit from the BCAA cuisine in terms of significantly higher food intake and subjective rating. The clinical liver function tests, however, did not show statistical difference between the BCAA group and the control group in the examination period of 14 days.

CONCLUSION

Our specifically designed BCAA-enriched diet resulted in greater patient satisfaction and compliance with nutrition. A larger trial or longer-term follow-up may be required to identify an effect on survival, recovery, surgical complications, protein profiles, and amino acid profiles.

Early Post-Operative Pancreatitis and Systemic Inflammatory Response Assessed by Serum Lipase and IL-6 Predict Pancreatic Fistula

Background

Post-operative pancreatic fistula (POPF) remains a critical complication after pancreatic resection. This prospective pilot study evaluates perioperative markers of pancreatitis and systemic inflammation to predict clinically relevant grade B/C-POPF (CR-POPF).

Methods

All patients undergoing pancreatic resection from December 2017 to April 2019 were prospectively enrolled. Surgical procedures and outcomes were correlated with perioperative blood markers. ROC analysis was performed to assess their predictive value for CR-POPF. Cut-offs were calculated with the Youden index.

Results

In total, 70 patients were analysed (43 pancreatoduodenectomies and 27 distal pancreatectomies). In-hospital/90-d mortality and morbidity were 5.7/7.1% (n = 4/n = 5) and 75.7% (n = 53). Major complications (Clavien–Dindo ≥ 3a) occurred in 28 (40.0%) patients, CR-POPF in 20 (28.6%) patients. Serum lipase (cut-off > 51U/L) and IL-6 (> 56.5 ng/l) on POD3 were significant predictors for CR-POPF (AUC = 0.799, 95%-CI 0.686–0.912 and AUC = 0.784, 95%-CI 0.668–0.900; combined AUC = 0.858, 95%-CI 0.758–0.958; all p < 0.001). Patients with both or one factor(s) above cut-off more frequently developed CR-POPF than cases without (100 vs. 50% vs. 7.5%, p < 0.001). This also applied for overall and severe complications (p = 0.013 and p = 0.009).

Conclusions

Post-operative pancreatitis and inflammatory response are major determinants for development of POPF. A combination of serum lipase and IL-6 on POD3 is a highly significant early predictor of CR-POPF and overall complications, potentially guiding patient management.

Clinical trial registration

The study protocol was registered at clinicaltrials.gov (NCT04294797)

Electronic supplementary material

The online version of this article (10.1007/s00268-020-05768-9) contains supplementary material, which is available to authorized users.

Gingival overgrowth caused by Olmesartan Medoxomil: Observational study

Objective: Olmesartan Medoxomil is a type 1 receptor antagonist an antagonist of type 1 receptor (AT1) of angiotensin II (A-II) that inhibits numerous actions of A-II in the renin-angiotensin-aldosterone system (RAAS). A-II is a significant and multifunctional peptide involved in the pathophysiology of blood hypertension and for this reason it represents the main target in several classes of drugs used to treat and control arterial hypertension, such as angiotensin converting enzyme inhibitors (ACE-i), angiotensin receptor blockers (ARB) and renin direct inhibitors. The aim of the study is to evaluate whether the two drugs that have as an active principle Olmesartan Medoxomil, with and without the diuretic hydrochlorothiazide, are able to determine gingival overgrowth. Study Design: 108 subjects were examined and divided into three groups: G1, subjects treated with Olmesartan Medoxomil and hydrochlorothiazide (n=60); G2, subjects received only Olmesartan Medoxomil (n=24); G3, control group without pharmacological therapies (n=24). The plaque index (IP) and the gingival overgrowth index (OI) were recorded, considering the vertical and horizontal components. Results: Vertical overgrowth averaged between 0.17 ± 0.15 (G3) and 0.34 ± 0.26 (G2) showing statistically significant differences (p <0.05) compared to the other groups. Horizontal overgrowth ranged from 0.18 ± 0.26 (G3) to 0.49 ± 0.35 (G2) showing statistically significant differences (p <0.05). Conclusions: antihypertensive agents as Olmesartan Medoxomil may result in mild gingival overgrowth in the upper and lower frontal dental elements not related to other etiological factors.

Magnesium alginate in children with uncontrolled asthma

Gastroesophageal reflux disease (GERD) may be frequently associated with asthma in children and may affect asthma control. Proton pump inhibitors (PPI) are commonly prescribed in asthmatic children, despite uncertain efficacy on respiratory symptoms and risk of relevant adverse effects.

Outcomes of pancreas retransplantation in patients with pancreas graft failure

Background

Pancreas retransplantation is still a controversial option after loss of a pancreatic graft. This article describes the experience of pancreas retransplantation at a high‐volume centre.

Methods

This was a retrospective observational study of all pancreas retransplantations performed in a single centre between 1997 and 2013. Pancreatic graft loss was defined by the return to insulin dependence. Risk factors for graft loss as well as patient and graft survival were analysed using logistic and time‐to‐event regression models.

Results

Of 409 pancreas transplantations undertaken, 52 (12·7 per cent) were identified as pancreas retransplantations. After a median follow‐up of 65·0 (range 0·8–174·3) months, 1‐ and 5‐year graft survival rates were 79 and 69 per cent respectively, and 1‐ and 5‐year patient survival rates were 96 and 89 per cent. During the entire follow‐up, 22 grafts (42 per cent) were lost. Patient survival was not associated with any of the donor‐ or recipient‐related factors investigated. Five‐year graft survival was better after simultaneous kidney–pancreas retransplantation than pancreas retransplantation alone: 80 per cent (16 of 20) versus 63 per cent (20 of 32) (P = 0·226). Acute rejection (odds ratio 4·49, 95 per cent c.i. 1·59 to 12·68; P = 0·005) and early surgical complications (OR 3·29, 1·09 to 9·99, P = 0·035) were identified as factors with an independent negative effect on graft survival.

Conclusion

Pancreas retransplantation may be considered for patients whose previous graft has failed.

Good outcome in selected patients

Integrating interventional oncology in the treatment of liver tumors

Background

Percutaneous ablation techniques offer a vast armamentarium for local, minimally invasive treatment of liver tumors, nowadays representing an established therapeutic option, which is integrated in treatment algorithms, especially for non-resectable liver tumors. The results of ablative treatment compare very well to surgical treatment in liver lesions, and confirm that these techniques are a valuable option for bridging for transplantation. Different techniques have been established to perform tumor ablation, and the feasibility varies according to the procedure and technical skills of the operator, depending on the size and location of the liver lesion. In recent years, stereotactic multi-needle techniques using 3D trajectory planning, general anesthesia, and tube disconnection during needle placement have had a strong impact on the application range of ablation for liver tumors.

Conclusion

It is well known that creating a sufficient ablation margin and overlapping ablation zones is one key issue to enable ablation of large liver lesions with tumor-free margins (A0 ablation in analogy to R0 resection). Image fusion during treatment and follow-up assure highly accurate staging procedures and interventional planning.

Novel aspects

Review on the standards in ablation techniques for the treatment of liver tumors. Update on different ablation techniques, indications, and contraindications for percutaneous liver tumor treatment. Summary of recently published reports on liver tumor ablation.

TRICARE Applied Behavior Analysis (ABA) Benefit: Comparison with Medicaid and Commercial Benefits

This study compared the Applied Behavior Analysis (ABA) benefit provided by TRICARE as an early intervention for autism spectrum disorder with similar benefits in Medicaid and commercial health insurance plans. The sponsor, the Office of the Under Secretary of Defense for Personnel and Readiness, was particularly interested in how a proposed TRICARE reimbursement rate decrease from $125 per hour to $68 per hour for ABA services performed by a Board Certified Behavior Analyst compared with reimbursement rates (defined as third-party payment to the service provider) in Medicaid and commercial health insurance plans. Information on ABA coverage in state Medicaid programs was collected from Medicaid state waiver databases; subsequently, Medicaid provider reimbursement data were collected from state Medicaid fee schedules. Applied Behavior Analysis provider reimbursement in the commercial health insurance system was estimated using Truven Health MarketScan® data. A weighted mean U.S. reimbursement rate was calculated for several services using cross-state information on the number of children diagnosed with autism spectrum disorder. Locations of potential provider shortages were also identified. Medicaid and commercial insurance reimbursement rates varied considerably across the United States. This project concluded that the proposed $68-per-hour reimbursement rate for services provided by a board certified analyst was more than 25 percent below the U.S. mean.

Local vs general anaesthesia in the development of neurosensory disturbances after mandibular third molars extraction: A retrospective study of 534 cases

BACKGROUND

The choice of the anaesthetic modality is one of the primary steps during planning of third molar surgery. The aim of the present study was to compare the risk of developing neurological injures of the inferior alveolar nerve (IAN) and lingual nerve (LN) in patients treated for wisdom teeth removal under general anaesthesia (GA) with a group treated under local anaesthesia (LA).

MATERIAL AND METHODS

This is an observational retrospective, unicentric study; between September 2013 and September 2014, 534 patients underwent third molar surgery, 194 (36,3%) under GA and 340 (63,7%) under LA by the same oral surgeon. Difference in the incidence of IAN and LN injures between groups have been statistically analyzed with Fisher exact test and estimated odd ratio for development of such complications has been calculated.

RESULTS

In GA patients the incidence of IAN and LN injures was 4.6% and 2.1%, respectively while in the LA group it was and 0.3% and 0%, respectively. A significant difference in IAN and LN involvement between groups was observed (IAN lesion: Fisher exact test, p<0.001; LN lesions: Fisher exact test, p<0.05). The estimated odd ratio for development of IAN injures after GA was 16.49 (95% CI: 2.07-131.19) and was not calculable for LN injures because no cases were observed in the LA group.

CONCLUSIONS

Since GA is a perioperative variable that seems to significantly increase the risk of developing IAN and LN lesions, when treating patients that request GA, they must be adequately informed that an higher incidence of post-surgical sensory disturbances is expected.

Synthesis of dense arrays of multiferroic CoFe2O4–PbZr0.52Ti0.48O3 core/shell nanocables

A major challenge in the development of efficient magnetoelectric nanocomposites is the adequate control of the interfaces, in order to avoid the formation of undesirable interphases and to ensure an optimal strain mediated coupling.

Sodium hyaluronate improves quality of life and nasal endoscopy features in preschool children with upper respiratory tract infections

The aim of this prospective, randomised study was to evaluate the effects of nasal douches with sodium hyaluronate on clinical and endoscopic variables, on parental perception of their child’s health-related quality of life (HR-QoL), and on parental workdays lost in preschool recurrent upper respiratory tract infections (URTIs). Children aged 2-6 years with recurrent or persistent URTIs underwent at baseline the evaluation of upper respiratory tract symptoms in the previous two weeks, and nasal endoscopy. Parents of enrolled children were assessed for self-perception of their children’s HR-QoL using a standardised questionnaire. The same variables were reassessed after a 2-week treatment with either 9 mg sodium hyaluronate plus saline solution or saline alone by nasal douches. Forty of the 48 children enrolled completed the study (22 assigned to the combined treatment). Compared to baseline, the combined treatment resulted in a significant reduction of the prevalence of children with missed daycare days (45% vs 14%, p=0.04) and of parents with workdays lost (36% vs 5%, p=0.02), and in a significant improvement of HR-QoL score (3.7 vs 2.8, p=0.004). At endoscopy, the secretion and mucosal oedema score significantly improved after the combined treatment (6 vs 2, p < 0.001), and there was a trend towards a reduction of the adenoid hypertrophy score (p=0.06). No clinical, HR-QOL or endoscopy changes were found in the saline group. In preschool children with recurrent or persistent URTIs, sodium hyaluronate by nasal douche significantly improves endoscopic features. Additional benefits include the children’s HR-QoL and daycare attendance, and parental work.

Treatment with tetrahydrobiopterin overcomes brain death-associated injury in a murine model of pancreas transplantation

Brain death (BD) has been associated with an immunological priming of donor organs and is thought to exacerbate ischemia reperfusion injury (IRI). Recently, we showed that the essential nitric oxide synthase co-factor tetrahydrobiopterin (BH4) abrogates IRI following experimental pancreas transplantation. We therefore studied the effects of BD in a murine model of syngeneic pancreas transplantation and tested the therapeutic potential of BH4 treatment. Compared with sham-operated controls, donor BD resulted in intragraft inflammation reflected by induced IL-1ß, IL-6, VCAM-1, and P-selectin mRNA expression levels and impaired microcirculation after reperfusion (p < 0.05), whereas pretreatment of the BD donor with BH4 significantly improved microcirculation after reperfusion (p < 0.05). Moreover, BD had a devastating impact on cell viability, whereas BH4-treated grafts showed a significantly higher percentage of viable cells (p < 0.001). Early parenchymal damage in pancreatic grafts was significantly more pronounced in organs from BD donors than from sham or non-BD donors (p < 0.05), but BH4 pretreatment significantly ameliorated necrotic lesions in BD organs (p < 0.05). Pretreatment of the BD donor with BH4 resulted in significant recipient survival (p < 0.05). Our data provide novel insights into the impact of BD on pancreatic isografts, further demonstrating the potential of donor pretreatment strategies including BH4 for preventing BD-associated injury after transplantation.

Calibre Persistent Labial Artery: Clinical Features and Immunohistochemistry Diagnosis

Calibre persistent labial artery (CPLA) usually presents as an asymptomatic papule on the lower lip and can be easily misdiagnosed as a mucocele, haemangioma, venous lake, varix or fibroma. When it is ulcerated, squamous cell carcinoma is the most usual differential diagnosis. Here, we report a case of a 25-year-old woman with no previous relevant medical history who presented with a complaint of an asymptomatic, non-ulcerated, progressively growing nodule (over the last 5 months) on the upper lip. In this case, the diagnosis was made clinically and confirmed by immunohistochemical analysis. We conclude that clinicians should be aware of CPLA and it should be included in the differential diagnosis of labial mucosal papules. Sometimes, the immunohistochemical analysis is necessary to make a correct diagnosis.

Defect chemistry in ferroelectric perovskites: long standing issues and recent advances

Accurate control of residual defect density is required for reliable investigation and use of ferroelectric materials.

Systematic tuning of the conduction mechanisms in ferroelectric thin films

We have investigated the macroscopic and microscopic properties of large sets of Ba0.7Sr0.3TiO3 thin films including several substitution rates of manganese. Thanks to a high degree of control of the processing parameters at each stage we have been able to find a link between the dc leakage current and the low and high frequency dielectric permittivity and losses. We supplemented these macroscopic observations with in depth investigations of the defect states through x-ray photoelectron spectroscopy. We found that both the leakage current and the extrinsic dielectric parameters arise from a large density of charged point defects related to oxygen vacancies. At the outer surfaces of the films, the density of such charged defects is so high that it can raise the Fermi level to close to the conduction band. Such degradation of the films' performance can be relieved by appropriate manganese substitution for the titanium host ions. Such doping is able to move back the Fermi level to close to the center of the bandgap thus changing the conduction process from interfacial Schottky to bulk Poole Frenkel and decreasing the extrinsic losses. This beneficial effect was already inferred in ceramics and thin films but we have established a clear link between the macroscopic parameters and the microscopic defect state. This model can be transferred to many high permittivity oxides.

Bariatric surgery for weight loss and glycemic control in nonmorbidly obese adults with diabetes: a systematic review

IMPORTANCE

Bariatric surgery is beneficial in persons with a body mass index (BMI) of 35 or greater with obesity-related comorbidities. There is interest in using these procedures in persons with lower BMI and diabetes.

OBJECTIVE

To assess the association between bariatric surgery vs nonsurgical treatments and weight loss and glycemic control among patients with diabetes or impaired glucose tolerance and BMI of 30 to 35.

EVIDENCE REVIEW

PubMed, EMBASE, and Cochrane Library databases were searched from January 1985 through September 2012. Of 1291 screened articles, we included 32 surgical studies, 11 systematic reviews on nonsurgical treatments, and 11 large nonsurgical studies published after those reviews. Weight loss, metabolic outcomes, and adverse events were abstracted by 2 independent reviewers.

FINDINGS

Three randomized clinical trials (RCTs) (N = 290; including 1 trial of 150 patients with type 2 diabetes and mean BMI of 37, 1 trial of 80 patients without diabetes [38% with metabolic syndrome] and BMI of 30 to 35, and 1 trial of 60 patients with diabetes and BMI of 30 to 40 [13 patients with BMI <35]) found that surgery was associated with greater weight loss (range, 14.4-24 kg) and glycemic control (range, 0.9-1.43 point improvements in hemoglobin A1c levels) during 1 to 2 years of follow-up than nonsurgical treatment. Indirect comparisons of evidence from observational studies of bariatric procedures (n ≈ 600 patients) and meta-analyses of nonsurgical therapies (containing more than 300 RCTs) support this finding at 1 or 2 years of follow-up. However, there are no robust surgical data beyond 5 years of follow-up on outcomes of diabetes, glucose control, or macrovascular and microvascular outcomes. In contrast, some RCT data of nonsurgical therapies show benefits at 10 years of follow-up or more. Surgeon-reported adverse events were low (eg, hospital deaths of 0.3%-1.0%), but data were from select centers and surgeons. Long-term adverse events are unknown.

CONCLUSIONS AND RELEVANCE

Current evidence suggests that, when compared with nonsurgical treatments, bariatric surgical procedures in patients with a BMI of 30 to 35 and diabetes are associated with greater short-term weight loss and better intermediate glucose outcomes. Evidence is insufficient to reach conclusions about the appropriate use of bariatric surgery in this population until more data are available about long-term outcomes and complications of surgery.

Depression and medication adherence in the treatment of chronic diseases in the United States: a meta-analysis

OBJECTIVE

To conduct a meta-analysis of the association between depression and medication adherence among patients with chronic diseases. Poor medication adherence may result in worse outcomes and higher costs than if patients fully adhere to their medication regimens.

DATA SOURCES

We searched the PubMed and PsycINFO databases, conducted forward searches for articles that cited major review articles, and examined the reference lists of relevant articles.

STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS

We included studies on adults in the United States that reported bivariate relationships between depression and medication adherence. We excluded studies on special populations (e.g., substance abusers) that were not representative of the general adult population with chronic diseases, studies on certain diseases (e.g., HIV) that required special adherence protocols, and studies on interventions for medication adherence.

STUDY APPRAISAL AND SYNTHESIS METHODS

Data abstracted included the study population, the protocol, measures of depression and adherence, and the quantitative association between depression and medication adherence. Synthesis of the data followed established statistical procedures for meta-analysis.

RESULTS

The estimated odds of a depressed patient being non-adherent are 1.76 times the odds of a non-depressed patient, across 31 studies and 18,245 participants. The association was similar across disease types but was not as strong among studies that used pharmacy records compared to self-report and electronic cap measures.

LIMITATIONS

The meta-analysis results are correlations limiting causal inferences, and there is some heterogeneity among the studies in participant characteristics, diseases studied, and methods used.

CONCLUSIONS

This analysis provides evidence that depression is associated with poor adherence to medication across a range of chronic diseases, and we find a new potential effect of adherence measurement type on this relationship. Although this study cannot assess causality, it supports the importance that must be placed on depression in studies that assess adherence and attempt to improve it.

Efficacy and comparative effectiveness of atypical antipsychotic medications for off-label uses in adults: a systematic review and meta-analysis

CONTEXT

Atypical antipsychotic medications are commonly used for off-label conditions such as agitation in dementia, anxiety, and obsessive-compulsive disorder.

OBJECTIVE

To perform a systematic review on the efficacy and safety of atypical antipsychotic medications for use in conditions lacking approval for labeling and marketing by the US Food and Drug Administration.

DATA SOURCES AND STUDY SELECTION

Relevant studies published in the English language were identified by searches of 6 databases (PubMed, EMBASE, CINAHL, PsycInfo, Cochrane DARE, and CENTRAL) from inception through May 2011. Controlled trials comparing an atypical antipsychotic medication (risperidone, olanzapine, quetiapine, aripiprazole, ziprasidone, asenapine, iloperidone, or paliperidone) with placebo, another atypical antipsychotic medication, or other pharmacotherapy for adult off-label conditions were included. Observational studies with sample sizes of greater than 1000 patients were included to assess adverse events.

DATA EXTRACTION

Independent article review and study quality assessment by 2 investigators.

DATA SYNTHESIS

Of 12 228 citations identified, 162 contributed data to the efficacy review. Among 14 placebo-controlled trials of elderly patients with dementia reporting a total global outcome score that includes symptoms such as psychosis, mood alterations, and aggression, small but statistically significant effects sizes ranging from 0.12 and 0.20 were observed for aripiprazole, olanzapine, and risperidone. For generalized anxiety disorder, a pooled analysis of 3 trials showed that quetiapine was associated with a 26% greater likelihood of a favorable response (defined as at least 50% improvement on the Hamilton Anxiety Scale) compared with placebo. For obsessive-compulsive disorder, risperidone was associated with a 3.9-fold greater likelihood of a favorable response (defined as a 25% improvement on the Yale-Brown Obsessive Compulsive Scale) compared with placebo. In elderly patients, adverse events included an increased risk of death (number needed to harm [NNH] = 87), stroke (NNH = 53 for risperidone), extrapyramidal symptoms (NNH = 10 for olanzapine; NNH = 20 for risperidone), and urinary tract symptoms (NNH range = 16-36). In nonelderly adults, adverse events included weight gain (particularly with olanzapine), fatigue, sedation, akathisia (for aripiprazole), and extrapyramidal symptoms.

CONCLUSIONS

Benefits and harms vary among atypical antipsychotic medications for off-label use. For global behavioral symptom scores associated with dementia in elderly patients, small but statistically significant benefits were observed for aripiprazole, olanzapine, and risperidone. Quetiapine was associated with benefits in the treatment of generalized anxiety disorder, and risperidone was associated with benefits in the treatment of obsessive-compulsive disorder; however, adverse events were common.

Updating comparative effectiveness reviews: current efforts in AHRQ's Effective Health Care Program

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.

Development quality criteria to evaluate nontherapeutic studies of incidence, prevalence, or risk factors of chronic diseases: pilot study of new checklists

OBJECTIVE

To develop two checklists for the quality of observational studies of incidence or risk factors of diseases.

STUDY DESIGN AND SETTING

Initial development of the checklists was based on a systematic literature review. The checklists were refined after pilot trials of validity and reliability were conducted by seven experts, who tested the checklists on 10 articles.

RESULTS

The checklist for studies of incidence or prevalence of chronic disease had six criteria for external validity and five for internal validity. The checklist for risk factor studies had six criteria for external validity, 13 criteria for internal validity, and two aspects of causality. A Microsoft Access database produced automated standardized reports about external and internal validities. Pilot testing demonstrated face and content validities and discrimination of reporting vs. methodological qualities. Interrater agreement was poor. The experts suggested future reliability testing of the checklists in systematic reviews with preplanned protocols, a priori consensus about research-specific quality criteria, and training of the reviewers.

CONCLUSION

We propose transparent and standardized quality assessment criteria of observational studies using the developed checklists. Future testing of the checklists in systematic reviews is necessary to develop reliable tools that can be used with confidence.

Development quality criteria to evaluate nontherapeutic studies of incidence, prevalence, or risk factors of chronic diseases: pilot study of new checklists

OBJECTIVE

To develop two checklists for the quality of observational studies of incidence or risk factors of diseases.

STUDY DESIGN AND SETTING

Initial development of the checklists was based on a systematic literature review. The checklists were refined after pilot trials of validity and reliability were conducted by seven experts, who tested the checklists on 10 articles.

RESULTS

The checklist for studies of incidence or prevalence of chronic disease had six criteria for external validity and five for internal validity. The checklist for risk factor studies had six criteria for external validity, 13 criteria for internal validity, and two aspects of causality. A Microsoft Access database produced automated standardized reports about external and internal validities. Pilot testing demonstrated face and content validities and discrimination of reporting vs. methodological qualities. Interrater agreement was poor. The experts suggested future reliability testing of the checklists in systematic reviews with preplanned protocols, a priori consensus about research-specific quality criteria, and training of the reviewers.

CONCLUSION

We propose transparent and standardized quality assessment criteria of observational studies using the developed checklists. Future testing of the checklists in systematic reviews is necessary to develop reliable tools that can be used with confidence.

Donor pretreatment with tetrahydrobiopterin saves pancreatic isografts from ischemia reperfusion injury in a mouse model

Depletion of the nitric oxide synthase cofactor tetrahydrobiopterin (H4B) during ischemia and reperfusion is associated with severe graft pancreatitis. Since clinically feasible approaches to prevent ischemia reperfusion injury (IRI) by H4B-substitution are missing we investigated its therapeutic potential in a murine pancreas transplantation model using different treatment regimens. Grafts were subjected to 16 h cold ischemia time (CIT) and different treatment regimens: no treatment, 160 μM H4B to perfusion solution, H4B 50 mg/kg prior to reperfusion and H4B 50 mg/kg before recovery of organs. Nontransplanted animals served as controls. Recipient survival and endocrine graft function were assessed. Graft microcirculation was analyzed 2 h after reperfusion by intravital fluorescence microscopy. Parenchymal damage was assessed by histology and nitrotyrosine immunohistochemistry, H4B tissue levels by high pressure liquid chromatography (HPLC). Compared to nontransplanted controls prolonged CIT resulted in significant microcirculatory deterioration. Different efficacy according to route and timing of administration could be observed. Only donor pretreatment with H4B resulted in almost completely abrogated IRI-related damage showing graft microcirculation comparable to nontransplanted controls and restored intragraft H4B levels, resulting in significant reduction of parenchymal damage (p < 0.002) and improved survival and endocrine function (p = 0.0002 each). H4B donor pretreatment abrogates ischemia-induced parenchymal damage and represents a promising strategy to prevent IRI following pancreas transplantation.

Diagnosing and managing common food allergies: a systematic review

CONTEXT

There is heightened interest in food allergies but no clear consensus exists regarding the prevalence or most effective diagnostic and management approaches to food allergies.

OBJECTIVE

To perform a systematic review of the available evidence on the prevalence, diagnosis, management, and prevention of food allergies.

DATA SOURCES

Electronic searches of PubMed, Cochrane Database of Systematic Reviews, Cochrane Database of Abstracts of Reviews of Effects, and Cochrane Central Register of Controlled Trials. Searches were limited to English-language articles indexed between January 1988 and September 2009.

STUDY SELECTION

Diagnostic tests were included if they had a prospective, defined study population, used food challenge as a criterion standard, and reported sufficient data to calculate sensitivity and specificity. Systematic reviews and randomized controlled trials (RCTs) for management and prevention outcomes were also used. For foods where anaphylaxis is common, cohort studies with a sample size of more than 100 participants were included.

DATA EXTRACTION

Two investigators independently reviewed all titles and abstracts to identify potentially relevant articles and resolved discrepancies by repeated review and discussion. Quality of systematic reviews and meta-analyses was assessed using the AMSTAR criteria, the quality of diagnostic studies using the QUADAS criteria most relevant to food allergy, and the quality of RCTs using the Jadad criteria.

DATA SYNTHESIS

A total of 12,378 citations were identified and 72 citations were included. Food allergy affects more than 1% to 2% but less than 10% of the population. It is unclear if the prevalence of food allergies is increasing. Summary receiver operating characteristic curves comparing skin prick tests (area under the curve [AUC], 0.87; 95% confidence interval [CI], 0.81-0.93) and serum food-specific IgE (AUC, 0.84; 95% CI, 0.78-0.91) to food challenge showed no statistical superiority for either test. Elimination diets are the mainstay of therapy but have been rarely studied. Immunotherapy is promising but data are insufficient to recommend use. In high-risk infants, hydrolyzed formulas may prevent cow's milk allergy but standardized definitions of high risk and hydrolyzed formula do not exist.

CONCLUSION

The evidence for the prevalence and management of food allergy is greatly limited by a lack of uniformity for criteria for making a diagnosis.

[Measles and its secondary pulmonary complications: prevention is better than treatment]

Recent measles outbreaks observed in North America and in several European countries, including Italy, raised the attention about the risks linked to this infection and the need of implementing and maintaining adequate preventive strategies. Measles may cause several respiratory complications such as chronic obstructive lung disease, pneumonia, with subsequent development of chronic suppurative lung disease, giant cells pneumonia or progressive respiratory insufficiency. The current preventive strategies aim to improve vaccination coverage rates with 2 doses of measles-mumps and rubella vaccine, and to catch up individuals who have not been previously vaccinated. The present review analyses pulmonary complications of measles and measles preventive strategies. Elimination of measles is a feasible goal. Since measles complications are preventable by vaccination, improvement in vaccination coverage is highly desirable.

Pregnancy and fertility following bariatric surgery: a systematic review

CONTEXT

Use of bariatric surgery has increased dramatically during the past 10 years, particularly among women of reproductive age.

OBJECTIVES

To estimate bariatric surgery rates among women aged 18 to 45 years and to assess the published literature on pregnancy outcomes and fertility after surgery.

EVIDENCE ACQUISITION

Search of the Nationwide Inpatient Sample (1998-2005) and multiple electronic databases (Medline, EMBASE, Controlled Clinical Trials Register Database, and the Cochrane Database of Reviews of Effectiveness) to identify articles published between 1985 and February 2008 on bariatric surgery among women of reproductive age. Search terms included bariatric procedures, fertility, contraception, pregnancy, and nutritional deficiencies. Information was abstracted about study design, fertility, and nutritional, neonatal, and pregnancy outcomes after surgery.

EVIDENCE SYNTHESIS

Of 260 screened articles, 75 were included. Women aged 18 to 45 years accounted for 49% of all patients undergoing bariatric surgery (>50,000 cases annually for the 3 most recent years). Three matched cohort studies showed lower maternal complication rates after bariatric surgery than in obese women without bariatric surgery, or rates approaching those of nonobese controls. In 1 matched cohort study that compared maternal complication rates in women after laparoscopic adjustable gastric band surgery with obese women without surgery, rates of gestational diabetes (0% vs 22.1%, P < .05) and preeclampsia (0% vs 3.1%, P < .05) were lower in the bariatric surgery group. Findings were supported by 13 other bariatric cohort studies. Neonatal outcomes were similar or better after surgery compared with obese women without laparoscopic adjustable gastric band surgery (7.7% vs 7.1% for premature delivery; 7.7% vs 10.6% for low birth weight, P < .05; 7.7% vs 14.6% for macrosomia, P < .05). No differences in neonatal outcomes were found after gastric bypass compared with nonobese controls (26.3%-26.9% vs 22.4%-20.2% for premature delivery, P = not reported [1 study] and P = .43 [1 study]; 7.7% vs 9.0% for low birth weight, P = not reported [1 study]; and 0% vs 2.6%-4.3% for macrosomia, P = not reported [1 study] and P = .28 [1 study]). Findings were supported by 10 other studies. Studies regarding nutrition, fertility, cesarean delivery, and contraception were limited.

CONCLUSION

Rates of many adverse maternal and neonatal outcomes may be lower in women who become pregnant after having had bariatric surgery compared with rates in pregnant women who are obese; however, further data are needed from rigorously designed studies.

Bariatric surgery in women of reproductive age: special concerns for pregnancy

CONTEXT

The use of bariatric surgery for treating severe obesity has increased dramatically over the past 10 years; about half of patients who undergo these procedures are women of reproductive age. This report was commissioned to measure the incidence of bariatric surgery in this population and review the evidence on the impact of bariatric surgery on fertility and subsequent pregnancy.

OBJECTIVES

To measure the incidence of contemporary bariatric surgery procedures in women age 18-45 and to assess its impact on fertility, contraception, prepregnancy risk factors, and pregnancy outcomes, including those of neonates.

DATA SOURCES AND STUDY SELECTION

Nationwide Inpatient Sample (NIS), a national sample of over 1,000 hospitals, to measure the trend in the number of women of reproductive age who underwent bariatric procedures from 1998-2005. We searched numerous electronic databases, including MEDLINE and Embase, for potentially relevant studies involving bariatric surgery (gastric bypass, laparoscopic adjustable gastric band, vertical-banded gastroplasty, biliopancreatic diversion), and consequent fertility, contraception, pregnancy, weight management, maternal and neonatal outcomes, and nutritional deficiencies. We scanned reference lists for additional relevant articles and contacted experts in the fields of bariatric surgery and obstetrics/gynecology (OB/GYN). Of 223 screened articles, we accepted 57 that reported on fertility following surgery (19 articles), contraception use/recommendations (11), maternal weight or nutrition management (28), maternal outcomes including morbidity and mortality (48), cesarean-section rates (16), and neonatal outcomes (44). These articles included reports on gastric bypass, both open and laparoscopic (27 articles), laparoscopic adjustable band (15), biliopancreatic diversion (16), and vertical-banded gastroplasty (6). Studies could contribute to one or more analyses. We found one case-control study and the observational data accepted included 12 cohort studies, 21 case series, and 23 individual case reports.

DATA EXTRACTION

We abstracted information about study design, fertility history, fertility outcomes, prepregnancy weight loss, nutritional management, outcomes following pregnancy, and adverse events (during pregnancy) related to surgery.

DATA SYNTHESIS

Nationally representative data showed a six-fold increase in bariatric surgery inpatient procedures from 1998 to 2005. Women age 18-45 accounted for about half of the patients undergoing bariatric surgery; over 50,000 have these procedures as inpatients annually. An unknown number have outpatient bariatric procedures. We identified one case-control study that directly addressed some of the key questions, but no randomized controlled trials or prospective cohort studies, which would be the strongest study designs to answer questions about effectiveness, risk and prognosis. Consequently, all of our conclusions are limited by the available data, and are cautious.The evidence suggests that bariatric surgery results in improved fertility; the strongest evidence is in women with the polycystic ovarian syndrome, where biochemical studies showing normalization of hormones after surgery support case series data. Observational studies (retrospective cohorts and case series) suggest that fertility improves following bariatric procedures and weight loss; similar to that seen when obese women lose weight through nonsurgical means. There is almost no evidence on post-surgical contraceptive efficacy or use. Research is needed to determine whether differences in absorption, particularly for oral contraceptives, affect contraceptive efficacy. Nutrient deficiencies were reported in infants born to women who underwent procedures that resulted in malabsorption, as well as women who did not take prenatal vitamins or had difficulty with their own nutrition (i.e., from chronic vomiting). Literature suggests that gastric bypass and laparoscopic adjustable band procedures confer only minimal, if any, increased risk of nutritional or congenital problems if supplemental vitamins are taken and maternal nutrition is otherwise adequate. Biliopancreatic diversion has an appreciable risk for nutritional problems in some patients. Women who have undergone bariatric surgery may have less risk than obese women for certain pregnancy complications such as gestational diabetes, preeclampsia, and pregnancy induced hypertension. There is no evidence that cesarean section rates and delivery complications are higher in the post-surgery group, but data are limited.

CONCLUSIONS

Weight loss procedures are being performed more frequently to treat morbid obesity, with a six-fold increase over a recent 7-year time span; almost half of all patients are women of reproductive age. The level of evidence on fertility, contraception, and pregnancy outcomes is limited to observational studies. Data suggest that fertility improves after bariatric surgical procedures, nutritional deficiencies for mother and child are minimal, and maternal and neonatal outcomes are acceptable with laparoscopic adjustable band and gastric bypass as long as adequate maternal nutrition and vitamin supplementation are maintained. There is no evidence that delivery complications are higher in post-surgery pregnancies.

The effectiveness of covering smoking cessation services for medicare beneficiaries

OBJECTIVE

To examine whether reimbursement for Provider Counseling, Pharmacotherapies, and a telephone Quitline increase smoking cessation relative to Usual Care.

STUDY DESIGN

Randomized comparison trial testing the effectiveness of four smoking cessation benefits.

SETTING

Seven states that best represented the national population in terms of the proportion of those > or = 65 years of age and smoking rate.

PARTICIPANTS

There were 7,354 seniors voluntarily enrolled in the Medicare Stop Smoking Program and they were followed-up for 12 months.

INTERVENTION(S)

(1) Usual Care, (2) reimbursement for Provider Counseling, (3) reimbursement for Provider Counseling with Pharmacotherapy, and (4) telephone counseling Quitline with nicotine patch.

MAIN OUTCOME MEASURE

Seven-day self-reported cessation at 6- and 12-month follow-ups.

PRINCIPAL FINDINGS

Unadjusted quit rates assuming missing data=smoking were 10.2 percent (9.0-11.5), 14.1 percent (11.7-16.5), 15.8 percent (14.4-17.2), and 19.3 percent (17.4-21.2) at 12 months for the Usual Care, Provider Counseling, Provider Counseling + Pharmacotherapy, and Quitline arms, respectively. Results were robust to sociodemographics, smoking history, motivation, health status, and survey nonresponse. The additional cost per quitter (relative to Usual Care) ranged from several hundred dollars to $6,450.

CONCLUSIONS

A telephone Quitline in conjunction with low-cost Pharmacotherapy was the most effective means of reducing smoking in the elderly.