A Scoping Review to Explore the Potential Benefits of Nutrition Interventions for Latino/a Adult Cancer Survivors in the US.

Despite evidence for the role of healthy diets in preventing cancer, little is known about how nutrition can support positive health outcomes after a cancer diagnosis for Latino/a cancer survivors in the United States (U.S.). The purpose of this scoping review is to understand the potential benefits of nutrition interventions in supporting healthy survivorship among Latino/a cancer survivors in the U.S. A team compiled, evaluated, and summarized the available evidence. Potentially relevant studies were identified from a comprehensive search of peer-reviewed databases and the gray literature. Eligible studies included Latino/a adult cancer survivors with a nutrition education, dietary change, or behavioral intervention; and a nutrition-related health outcome. Data were extracted and summarized using tables. The review included 10 randomized controlled trials, with samples or subsamples of Latino/a cancer survivors. Interventions mostly focused on breast cancer survivors. The results showed some evidence that dietary behaviors, like fruit and vegetable intake, were related to positive outcomes, like a decreased risk of cancer (through changes in DNA methylation), decreased risk breast cancer recurrence (through changes in inflammatory biomarkers), or improved perception of health status. The findings highlight a need for community-engaged and culturally relevant nutrition interventions for Latino/a adults, especially for rural communities; and innovative intervention approaches, including m/ehealth approaches with long-term follow-up.

Local connectivity and synaptic dynamics in mouse and human neocortex.

We present a unique, extensive, and open synaptic physiology analysis platform and dataset. Through its application, we reveal principles that relate cell type to synaptic properties and intralaminar circuit organization in the mouse and human cortex. The dynamics of excitatory synapses align with the postsynaptic cell subclass, whereas inhibitory synapse dynamics partly align with presynaptic cell subclass but with considerable overlap. Synaptic properties are heterogeneous in most subclass-to-subclass connections. The two main axes of heterogeneity are strength and variability. Cell subclasses divide along the variability axis, whereas the strength axis accounts for substantial heterogeneity within the subclass. In the human cortex, excitatory-to-excitatory synaptic dynamics are distinct from those in the mouse cortex and vary with depth across layers 2 and 3.

Enhancer viruses for combinatorial cell-subclass-specific labeling.

Rapid cell type identification by new genomic single-cell analysis methods has not been met with efficient experimental access to these cell types. To facilitate access to specific neural populations in mouse cortex, we collected chromatin accessibility data from individual cells and identified enhancers specific for cell subclasses and types. When cloned into recombinant adeno-associated viruses (AAVs) and delivered to the brain, these enhancers drive transgene expression in specific cortical cell subclasses. We extensively characterized several enhancer AAVs to show that they label different projection neuron subclasses as well as a homologous neuron subclass in human cortical slices. We also show how coupling enhancer viruses expressing recombinases to a newly generated transgenic mouse, Ai213, enables strong labeling of three different neuronal classes/subclasses in the brain of a single transgenic animal. This approach combines unprecedented flexibility with specificity for investigation of cell types in the mouse brain and beyond.

Fungi as Biocontrol Agents of Culicoides Biting Midges, the Putative Vectors of Bluetongue Disease.

Biting midges of the genus Culicoides (Diptera: Ceratopogonidae) are the principal vectors of several notable viral pathogens infecting animal livestock. Sickness and animal deaths caused by the Culicoides-transmitted bluetongue virus, as well as the recent Schmallenberg virus outbreak, have threatened the livestock industry in Europe. Recent studies highlight how, in the near future, the application of "dry" fungal conidia of Metarhizium anisopliae in animal shelters and microenvironment (e.g., dung, manure, leaf litter, and livestock surroundings) may be used to control the Culicoides vector, thus, reducing the incidence of Culicoides-borne diseases.

A Suite of Transgenic Driver and Reporter Mouse Lines with Enhanced Brain-Cell-Type Targeting and Functionality.

Modern genetic approaches are powerful in providing access to diverse cell types in the brain and facilitating the study of their function. Here, we report a large set of driver and reporter transgenic mouse lines, including 23 new driver lines targeting a variety of cortical and subcortical cell populations and 26 new reporter lines expressing an array of molecular tools. In particular, we describe the TIGRE2.0 transgenic platform and introduce Cre-dependent reporter lines that enable optical physiology, optogenetics, and sparse labeling of genetically defined cell populations. TIGRE2.0 reporters broke the barrier in transgene expression level of single-copy targeted-insertion transgenesis in a wide range of neuronal types, along with additional advantage of a simplified breeding strategy compared to our first-generation TIGRE lines. These novel transgenic lines greatly expand the repertoire of high-precision genetic tools available to effectively identify, monitor, and manipulate distinct cell types in the mouse brain.

Menopausal hormone therapy for the primary prevention of chronic conditions: a systematic review to update the U.S. Preventive Services Task Force recommendations.

BACKGROUND: Menopausal hormone therapy to prevent chronic conditions is currently not recommended because of its adverse effects. PURPOSE: To update evidence about the effectiveness of hormone therapy in reducing risk for chronic conditions and adverse effects, and to examine whether outcomes vary among women in different subgroups. DATA SOURCES: MEDLINE (January 2002 to November 2011), Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews (through the 3rd quarter of 2011), Scopus, and reference lists. STUDY SELECTION: Randomized, placebo-controlled trials of menopausal hormone therapy published in English since 2002 that assessed primary prevention of chronic conditions. DATA EXTRACTION: Investigators extracted data on participants, study design, analysis, follow-up, and results; 2 investigators independently rated study quality by using established criteria. DATA SYNTHESIS: 9 fair-quality trials met the inclusion criteria. The Women's Health Initiative reported most of the results, had 11 years of follow-up, and had data most applicable to postmenopausal women in the United States. It showed that estrogen plus progestin therapy reduced fractures (46 fewer per 10 000 woman-years) and increased invasive breast cancer (8 more per 10 000 woman-years), stroke (9 more per 10 000 woman-years), deep venous thrombosis (12 more per 10 000 woman-years), pulmonary embolism (9 more per 10 000 woman-years), lung cancer death (5 more per 10 000 woman-years), gallbladder disease (20 more per 10 000 woman-years), dementia (22 more per 10 000 woman-years), and urinary incontinence (872 more per 10 000 woman-years). Estrogen-only therapy reduced fractures (56 fewer per 10 000 woman-years), invasive breast cancer (8 fewer per 10 000 woman-years), and death (2 fewer per 10 000 woman-years) and increased stroke (11 more per 10 000 woman-years), deep venous thrombosis (7 more per 10 000 woman-years), gallbladder disease (33 more per 10 000 woman-years), and urinary incontinence (1271 more per 10 000 woman-years). Outcomes did not consistently differ by age or comorbid conditions. LIMITATION: Limitations of the trials included low adherence, high attrition, inadequate power to detect risks for some outcomes, and evaluation of few regimens. CONCLUSION: Estrogen plus progestin and estrogen alone decreased risk for fractures but increased risk for stroke, thromboembolic events, gallbladder disease, and urinary incontinence. Estrogen plus progestin increased risk for breast cancer and probable dementia, whereas estrogen alone decreased risk for breast cancer. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

Closing the quality gap: revisiting the state of the science (vol. 5: public reporting as a quality improvement strategy).

OBJECTIVES: The goal of this review was to evaluate the effectiveness of public reporting of health care quality information as a quality improvement strategy. We sought to determine if public reporting results in improvements in health care delivery and patient outcomes. We also considered whether public reporting affects the behavior of patients or of health care providers. Finally we assessed whether the characteristics of the public reports and the context affect the impact of public reports. DATA SOURCES: Articles available between 1980 and 2011 were identified through searches of the following bibliographical databases: MEDLINE®, Embase, EconLit, PsychINFO, Business Source Premier, CINAHL, PAIS, Cochrane Database of Systematic Reviews, EPOC Register of Studies, DARE, NHS EED, HEED, NYAM Grey Literature Report database, and other sources (experts, reference lists, and gray literature). REVIEW METHODS: We screened citations based on inclusion and exclusion criteria developed based on our definition of public reporting. We initially did not exclude any studies based on study design. Of the 11,809 citations identified through title and abstract triage, we screened and reviewed 1,632 articles. A total of 97 quantitative and 101 qualitative studies were included, abstracted, entered into tables, and evaluated. The heterogeneity of outcomes as well as methods prohibited formal quantitative synthesis. Systematic reviews were used to identify studies, but their conclusions were not incorporated into this review. RESULTS: For most of the outcomes, the strength of the evidence available to assess the impact of public reporting was moderate. This was due in part to the methodological challenges researchers face in designing and conducting research on the impact of population-level interventions. Public reporting is associated with improvement in health care performance measures such as those included in Nursing Home Compare. Almost all identified studies found no evidence or only weak evidence that public reporting affects the selection of health care providers by patients or their representatives. Studies of health care providers' response to public reports suggest they engage in activities to improve quality when performance data are made public. Characteristics of public reports and the context, which are likely to be important when considering the diffusion of quality improvement activities, were rarely studied or even described. CONCLUSIONS: The heterogeneity of the outcomes and the moderate strength of evidence for most outcomes make it difficult to draw definitive conclusions. However, some observations were supported by existing research. Public reporting is more likely to be associated with changes in health care provider behaviors than with selection of health services providers by patients or families. Quality measures that are publicly reported improve over time. Although the potential for harms is frequently cited by commentators and critics of public reporting, the amount of research on harms is limited and most studies do not confirm the potential harm.

Screening asymptomatic adults with resting or exercise electrocardiography: a review of the evidence for the U.S. Preventive Services Task Force.

BACKGROUND: Coronary heart disease is the leading cause of death in adults. Screening for abnormalities by using resting or exercise electrocardiography (ECG) might help identify persons who would benefit from interventions to reduce cardiovascular risk. PURPOSE: To update the 2004 U.S. Preventive Services Task Force evidence review on screening for resting or exercise ECG abnormalities in asymptomatic adults. DATA SOURCES: MEDLINE (2002 through January 2011), the Cochrane Library database (through the fourth quarter of 2010), and reference lists. STUDY SELECTION: Randomized, controlled trials and prospective cohort studies. DATA EXTRACTION: Investigators abstracted details about the study population, study design, data analysis, follow-up, and results and assessed quality by using predefined criteria. DATA SYNTHESIS: No study evaluated clinical outcomes or use of risk-reducing therapies after screening versus no screening. No study estimated how accurately resting or exercise electrocardiography classified participants into high-, intermediate-, or low-risk groups, compared with traditional risk factor assessment alone. Sixty-three prospective cohort studies evaluated abnormalities on resting or exercise ECG as predictors of cardiovascular events after adjustment for traditional risk factors. Abnormalities on resting ECG (ST-segment or T-wave abnormalities, left ventricular hypertrophy, bundle branch block, or left-axis deviation) or exercise ECG (ST-segment depression with exercise, chronotropic incompetence, abnormal heart rate recovery, or decreased exercise capacity) were associated with increased risk (pooled hazard ratio estimates, 1.4 to 2.1). Evidence on harms was limited, but direct harms seemed minimal (for resting ECG) or small (for exercise ECG). No study estimated harms from subsequent testing or interventions, although rates of angiography after exercise ECG ranged from 0.6% to 2.9%. LIMITATIONS: Only English-language studies were included. Statistical heterogeneity was present in several of the pooled analyses. CONCLUSION: Abnormalities on resting or exercise ECG are associated with an increased risk for subsequent cardiovascular events after adjustment for traditional risk factors, but the clinical implications of these findings are unclear.

New insights on vaginal birth after cesarean: can it be predicted?

OBJECTIVE: To evaluate existing vaginal birth after cesarean (VBAC) screening tools and to identify additional factors that may predict VBAC or failed trial of labor. DATA SOURCES: Relevant studies were identified through MEDLINE, Database of Abstracts of Reviews of Effectiveness, and the Cochrane databases (1980-September 2009), and from recent systematic reviews, reference lists, reviews, editorials, web sites, and experts. METHODS OF STUDY SELECTION: Inclusion criteria limited studies to those of humans, written in English, studies conducted in the United States and developed countries, and those rated good or fair quality by the U.S. Preventive Services Task Force criteria. Studies of individual predictors were combined using a random effects model when the estimated odds ratios were comparable across included studies. TABULATION, INTEGRATION, AND RESULTS: We identified 3,134 citations and reviewed 963 papers, of which 203 met inclusion criteria and were quality-rated. Twenty-eight provided evidence on predictors of VBAC and 16 presented information on scored models for predicting VBAC (or failed trial of labor). Six of the 11 scored models for predicting VBAC (or failed trial of labor) were validated by separated dataset, cross-validation, or both. Whereas accuracy remained high across all models for predicting VBAC, with predictive values ranging from 88% to 95%, accuracy for predicting failed trial of labor was low, ranging from 33% to 58%. Individual predictors including Hispanic ethnicity, African-American race, advanced maternal age, no previous vaginal birth history, birth weight heavier than 4 kg, and use of either augmentation or induction were all associated with reduced likelihood of VBAC. CONCLUSION: Current scored models provide reasonable predictability for VBAC, but none provides consistent ability to identify women at risk for failed trial of labor. A scoring model is needed that incorporates known antepartum factors and can be adjusted for current obstetric factors and labor patterns if induction or augmentation is needed. This would allow women and clinicians to better determine individuals most likely to require repeat cesarean delivery.

Vaginal birth after cesarean: new insights.

OBJECTIVES: To synthesize the published literature on vaginal birth after cesarean (VBAC). Specifically, to review the trends and incidence of VBAC, maternal benefits and harms, infant benefits and harms, relevant factors influencing each, and the directions for future research. DATA SOURCES: Relevant studies were identified from multiple searches of MEDLINE; DARE; the Cochrane databases (1966 to September 2009); and from recent systematic reviews, reference lists, reviews, editorials, Web sites, and experts. REVIEW METHODS: Specific inclusion and exclusion criteria were developed to determine study eligibility. The target population includes healthy women of reproductive age, with a singleton gestation, in the U.S. with a prior cesarean who are eligible for a trial of labor (TOL) or elective repeat cesarean delivery (ERCD). All eligible studies were quality rated and data were extracted from good or fair quality studies, entered into tables, summarized descriptively and, when appropriate, pooled for analysis. The primary focus of the report was term pregnancies. However, due to a small number of studies on term pregnancies, general population studies including all gestational ages (GA) were included in appropriate areas. RESULTS: We identified 3,134 citations and reviewed 963 papers for inclusion, of which 203 papers met inclusion and were quality rated. Studies of maternal and infant outcomes reported data based upon actual rather than intended router of delivery. The range for TOL and VBAC rates was large (28-82 percent and 49-87 percent, respectively) with the highest rates being reported in studies outside of the U.S. Predictors of women having a TOL were having a prior vaginal delivery and settings of higher-level care (e.g., tertiary care centers). TOL rates in U.S. studies declined in studies initiated after 1996 from 63 to 47 percent, but the VBAC rate remained unimproved. Hispanic and African American women were less likely than their white counterparts to have a vaginal delivery. Overall rates of maternal harms were low for both TOL and ERCD. While rare for both TOL and ERCD, maternal mortality was significantly increased for ERCD at 13.4 per 100,000 versus 3.8 per 100,000 for TOL. The rates of maternal hysterectomy, hemorrhage, and transfusions did not differ significantly between TOL and ERCD. The rate of uterine rupture for all women with prior cesarean is 3 per 1,000 and the risk was significantly increased with TOL (4.7/1,000 versus 0.3/1,000 ERCD). Six percent of uterine ruptures were associated with perinatal death. No models have been able to accurately predict women who are more likely to deliver by VBAC or to rupture. Women with one prior cesarean delivery and previa had a statistically significant increased risk of adverse events compared with previa patients without a prior cesarean delivery; blood transfusion (15 versus 32.2 percent), hysterectomy (0.7 to 4 percent versus 10 percent), and composite maternal morbidity (15 versus 23-30 percent). Perinatal mortality was significantly increased for TOL at 1.3 per 1,000 versus 0.5 per 1,000 for ERCD. Insufficient data were found on nonmedical factors such as medical liability, economics, hospital staffing, structure and setting, which all appear to be important drivers for VBAC. CONCLUSIONS: Each year 1.5 million childbearing women have cesarean deliveries, and this population continues to increase. This report adds stronger evidence that VBAC is a reasonable and safe choice for the majority of women with prior cesarean. Moreover, there is emerging evidence of serious harms relating to multiple cesareans. Relatively unexamined contextual factors such as medical liability, economics, hospital structure, and staffing may need to be addressed to prioritize VBAC services. There is still no evidence to inform patients, clinicians, or policymakers about the outcomes of intended route of delivery because the evidence is based largely on the actual route of delivery. This inception cohort is the equivalent of intention to treat for randomized controlled trials and this gap in information is critical. A list of future research considerations as prioritized by national experts is also highlighted in this report.

Vaginal birth after cesarean: new insights on maternal and neonatal outcomes.

OBJECTIVE: To systematically review the evidence about maternal and neonatal outcomes relating to vaginal birth after cesarean (VBAC). DATA SOURCES: Relevant studies were identified from multiple searches of MEDLINE, DARE, and the Cochrane databases (1980 to September 2009) and from recent systematic reviews, reference lists, reviews, editorials, Web sites, and experts. METHODS OF STUDY SELECTION: Inclusion criteria limited studies to the English-language and human studies conducted in the United States and developed countries specifically evaluating birth after previous cesarean delivery. Studies focusing on high-risk maternal or neonatal conditions, including breech vaginal delivery, or fewer than 10 patients were excluded. Poor-quality studies were not included in analyses. TABULATION, INTEGRATION, AND RESULTS: We identified 3,134 citations and reviewed 963 articles for inclusion; 203 articles met the inclusion criteria and were quality rated. Overall rates of maternal harms were low for both trial of labor and elective repeat cesarean delivery. Although rare in both elective repeat cesarean delivery and trial of labor, maternal mortality was significantly increased for elective repeat cesarean delivery at 0.013% compared with 0.004% for trial of labor. The rates of maternal hysterectomy, hemorrhage, and transfusions did not differ significantly between trial of labor and elective repeat cesarean delivery. The rate of uterine rupture for all women with prior cesarean was 0.30%, and the risk was significantly increased for trial of labor (0.47% compared with 0.03% for elective repeat cesarean delivery). Perinatal mortality was also significantly increased for trial of labor (0.13% compared with 0.05% for elective repeat cesarean delivery). CONCLUSION: Overall the best evidence suggests that VBAC is a reasonable choice for the majority of women. Adverse outcomes were rare for both elective repeat cesarean delivery and trial of labor. Definitive studies are lacking to identify patients who are at greatest risk for adverse outcomes.

Barriers and drivers of health information technology use for the elderly, chronically ill, and underserved.

OBJECTIVES: We reviewed the evidence on the barriers and drivers to the use of interactive consumer health information technology (health IT) by specific populations, namely the elderly, those with chronic conditions or disabilities, and the underserved. DATA SOURCES: We searched MEDLINE, CINHAHL, PsycINFO the Cochrane Controlled Trials Register and Database of Systematic Reviews, ERIC, and the American Association of Retired Persons (AARP) AgeLine databases. We focused on literature 1990 to present. METHODS: We included studies of all designs that described the direct use of interactive consumer health IT by at least one of the populations of interest. We then assessed the quality and abstracted and summarized data from these studies with regard to the level of use, the usefulness and usability, the barriers and drivers of use, and the effectiveness of the interactive consumer health IT applications. RESULTS: We identified and reviewed 563 full-text articles and included 129 articles for abstraction. Few of the studies were specifically designed to compare the elderly, chronically ill, or underserved with the general population. We did find that several types of interactive consumer health IT were usable and effective in multiple settings and with all of our populations of interest. Of the studies that reported the impact of interactive consumer health IT on health outcomes, a consistent finding of our review was that these systems tended to have a positive effect when they provided a complete feedback loop that included: Monitoring of current patient status. Interpretation of this data in light of established, often individualized, treatment goals. Adjustment of the management plan as needed. Communication back to the patient with tailored recommendations or advice. Repetition of this cycle at appropriate intervals. Systems that provided only one or a subset of these functions were less consistently effective. The barriers and drivers to use were most often reported as secondary outcomes. Many studies were hampered by usability problems and unreliable technology, primarily due to the research being performed on early stage system prototypes. However, the most common factor influencing the successful use of the interactive technology by these specific populations was that the consumers' perceived a benefit from using the system. Convenience was an important factor. It was critical that data entry not be cumbersome and that the intervention fit into the user's daily routine. Usage was more successful if the intervention could be delivered on technology consumers used every day for other purposes. Finally, rapid and frequent interactions from a clinician improved use and user satisfaction. CONCLUSIONS: The systems described in the studies we examined depended on the active engagement of consumers and patients and the involvement of health professionals, supported by the specific technology interventions. Questions remain as to: The optimal frequency of use of the system by the patient, which is likely to be condition-specific. The optimal frequency of use or degree of involvement by health professionals. Whether the success depends on repeated modification of the patient's treatment regimen or simply ongoing assistance with applying a static treatment plan. However, it is clear that the consumer's perception of benefit, convenience, and integration into daily activities will serve to facilitate the successful use of the interactive technologies for the elderly, chronically ill, and underserved.

Complementary and alternative therapies for the management of menopause-related symptoms: a systematic evidence review.

BACKGROUND: Nearly half of adults in the United States use complementary and alternative therapies each year for a variety of reasons. These therapies are increasingly popular among women seeking alternatives to treatment with estrogen for managing menopausal symptoms. The objective of this review was to assess the effectiveness of complementary and alternative therapies in the management of menopausal symptoms. DATA SOURCES: MEDLINE, PsychINFO, Cochrane Library database, MANTIS, and AMED. STUDY SELECTION: Full-text, English-language, randomized controlled trials and meta-analyses comparing a complementary or alternative therapy with placebo or control for treatment of menopausal symptoms. DATA EXTRACTION: All eligible trials were reviewed, abstracted into evidence tables, and rated for quality. DATA SYNTHESIS: Seventy randomized controlled trials met inclusion criteria. Forty-eight studies of phytoestrogens and other biologically based agents showed mixed results. Smaller numbers of studies using mind-body, energy, manipulative, and body-based therapies and whole medical systems showed little benefit in treating menopausal symptoms. CONCLUSIONS: Although individual trials suggest benefits from certain therapies, data are insufficient to support the effectiveness of any complementary and alternative therapy in this review for the management of menopausal symptoms. Many of these potential therapies warrant further study in trials with rigorous scientific designs to determine benefit and safety.

Nonhormonal therapies for menopausal hot flashes: systematic review and meta-analysis.

CONTEXT: Concern regarding the adverse effects of estrogen and other hormones for treating menopausal symptoms has led to demand for other options; however, the efficacy and adverse effects of nonhormonal therapies are unclear. OBJECTIVE: To assess the efficacy and adverse effects of nonhormonal therapies for menopausal hot flashes by reviewing published randomized controlled trials. DATA SOURCES: MEDLINE (1966-October 2005), PsycINFO (1974-October 2005), and the Cochrane Controlled Clinical Trials Register Database (1966-October 2005) were searched for relevant trials that provided data on treatment of menopausal hot flashes using 1 or more nonhormonal therapies. STUDY SELECTION: All English-language, published, randomized, double-blind, placebo-controlled trials of oral nonhormonal therapies for treating hot flashes in menopausal women measuring and reporting hot flash frequency or severity outcomes. DATA EXTRACTION: Trials were identified, subjected to inclusion and exclusion criteria, and reviewed. Data on participants, interventions, and outcomes were extracted and trials were rated for quality based on established criteria. A meta-analysis was conducted for therapies with sufficient trials reporting hot flash frequency outcomes. DATA SYNTHESIS: From 4249 abstracts, 43 trials met inclusion criteria, including 10 trials of antidepressants, 10 trials of clonidine, 6 trials of other prescribed medications, and 17 trials of isoflavone extracts. The number of daily hot flashes decreased compared with placebo in meta-analyses of 7 comparisons of selective serotonin reuptake inhibitors (SSRIs) or serotonin norepinephrine reuptake inhibitors (SNRIs) (mean difference, -1.13; 95% confidence interval [CI], -1.70 to -0.57), 4 trials of clonidine (-0.95; 95% CI, -1.44 to -0.47), and 2 trials of gabapentin (-2.05; 95% CI, -2.80 to -1.30). Frequency was not reduced in meta-analysis of trials of red clover isoflavone extracts and results were mixed for soy isoflavone extracts. Evidence of the efficacy of other therapies is limited due to the small number of trials and their deficiencies. Trials do not compare different therapies head-to-head and relative efficacy cannot be determined. CONCLUSION: The SSRIs or SNRIs, clonidine, and gabapentin trials provide evidence for efficacy; however, effects are less than for estrogen, few trials have been published and most have methodological deficiencies, generalizability is limited, and adverse effects and cost may restrict use for many women. These therapies may be most useful for highly symptomatic women who cannot take estrogen but are not optimal choices for most women.

Screening for speech and language delay in preschool children: systematic evidence review for the US Preventive Services Task Force.

BACKGROUND: PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Published in the public domain by the American Academy of Pediatrics. Speech and language development is a useful indicator of a child's overall development and cognitive ability and is related to school success. Identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age, when the chances for improvement are best. However, optimal methods for screening for speech and language delay have not been identified, and screening is practiced inconsistently in primary care. PURPOSE: We sought to evaluate the strengths and limits of evidence about the effectiveness of screening and interventions for speech and language delay in preschool-aged children to determine the balance of benefits and adverse effects of routine screening in primary care for the development of guidelines by the US Preventive Services Task Force. The target population includes all children up to 5 years old without previously known conditions associated with speech and language delay, such as hearing and neurologic impairments. METHODS: Studies were identified from Medline, PsycINFO, and CINAHL databases (1966 to November 19, 2004), systematic reviews, reference lists, and experts. The evidence review included only English-language, published articles that are available through libraries. Only randomized, controlled trials were considered for examining the effectiveness of interventions. Outcome measures were considered if they were obtained at any time or age after screening and/or intervention as long as the initial assessment occurred while the child was < or =5 years old. Outcomes included speech and language measures and other functional and health outcomes such as social behavior. A total of 745 full-text articles met our eligibility criteria and were reviewed. Data were extracted from each included study, summarized descriptively, and rated for quality by using criteria specific to different study designs developed by the US Preventive Services Task Force. RESULTS: The use of risk factors for selective screening has not been evaluated, and a list of specific risk factors to guide primary care physicians has not been developed or tested. Sixteen studies about potential risk factors for speech and language delay in children enrolled heterogeneous populations, had dissimilar inclusion and exclusion criteria, and measured different risk factors and outcomes. The most consistently reported risk factors included a family history of speech and language delay, male gender, and perinatal factors. Other risk factors reported less consistently included educational levels of the mother and father, childhood illnesses, birth order, and family size. The performance characteristics of evaluation techniques that take < or =10 minutes to administer were described in 24 studies relevant to screening. Studies that were rated good to fair quality reported wide ranges of sensitivity and specificity when compared with reference standards (sensitivity: 17-100%; specificity: 45-100%). Most of the evaluations, however, were not designed for screening purposes, the instruments measured different domains, and the study populations and settings were often outside of primary care. No "gold standard" has been developed and tested for screening, reference standards varied across studies, few studies compared the performance of > or =2 screening techniques in 1 population, and comparisons of a single screening technique across different populations are lacking. Fourteen good- and fair-quality randomized, controlled trials of interventions reported significantly improved speech and language outcomes compared with control groups. Improvement was demonstrated in several domains including articulation, phonology, expressive language, receptive language, lexical acquisition, and syntax among children in all age groups studied and across multiple therapeutic settings. Improvement in other functional outcomes such as socialization skills, self-esteem, and improved play themes were demonstrated in some, but not all, of the 4 studies that measured them. In general, studies of interventions were small and heterogeneous, may be subject to plateau effects, and reported short-term outcomes based on various instruments and measures. As a result, long-term outcomes are not known, interventions could not be compared directly, and generalizability is questionable. CONCLUSIONS: Use of risk factors to guide selective screening is not supported by studies. Several aspects of screening have been inadequately studied to determine optimal methods, including which instrument to use, the age at which to screen, and which interval is most useful. Trials of interventions demonstrate improvement in some outcome measures, but conclusions and generalizability are limited. Data are not available addressing other key issues including the effectiveness of screening in primary care settings, role of enhanced surveillance by primary care physicians before referral for diagnostic evaluation, non-speech and language and long-term benefits of interventions, and adverse effects of screening and interventions.

Evaluation of three immunoassay kits for rapid detection of influenza virus A and B.

Influenza causes high morbidity and mortality in very young and elderly individuals, which can be controlled with antivirals and/or vaccines. The success of therapeutic measures is predicated on the rapid and precise diagnosis of the infection. We compared three rapid influenza immunoassay (RIIA) kits for the diagnosis of influenza virus A and B using 178 respiratory specimens submitted for routine testing. BD Directigen Flu A+B (Directigen), Directigen EZ Flu A+B (EZ), and NOW Flu A NOW Flu B (NOW; Binax) tests had comparable combined influenza virus A and B specificities, varying from 94 to 98%. In contrast, the sensitivity of EZ was significantly lower (39%) than that of NOW (76%) and marginally lower than that of Directigen (56%). The differences in sensitivity were most evident in patients who were >9 years old (Directigen, 53%; EZ, 32%; and NOW, 69%). Among specimens, bronchoalveolar lavage fluids yielded the most discrepant results, with sensitivities varying from 0 (EZ) to 100% (NOW), followed by nasopharyngeal swabs (sensitivities of 27 to 100%) and nasal washes (50 to 81%). The Directigen kit format allowed for faster completion but more cumbersome performance and more difficult interpretation compared with the other two kits. Overall, NOW provided the most accurate diagnoses and had user-friendly technical characteristics. However, the low overall sensitivity of the RIIAs indicates that these can be used as screening tools only.