What's Happening During Home Visits? Exploring the Relationship of Home Visiting Content and Dosage to Parenting Outcomes.

Introduction Research has documented modest positive impacts of early childhood home visiting programs. However, understanding more about what home visitors do during visits and how much time they spend on specific topics may provide insight into the variability in effectiveness of services. Methods Outcome data were collected via parent survey at program enrollment and 12 months from 123 women in three MIECHV-funded home visiting models. Home visitors completed weekly home visit content and activity logs. Results Families received an average of 28 visits during the study (3.1 visits per month). Of ten content areas, the three most often discussed were early childhood development, physical care of children, and the parent-child-relationship. Multivariate regression models were used to explore the association of home visit dosage, home visit content and cumulative risk factors on parenting outcomes. Women whose visits were focused more on parenting topics reported lower parenting-related stress at follow-up compared to those whose visits had less parenting content. Additionally, higher-risk women who received greater numbers of home visits showed larger reductions in their attitudes about harsh punishment over time, compared to high-risk women with fewer home visits. Discussion Receiving home visits that emphasize parenting content may contribute to reduced parenting-related stress. For high-risk women in particular, receiving more visits overall may be important to achieving positive outcomes. Implications for practice include working to engage and retain high-risk families. Future home visiting research calls for improved methods for collecting data on content/activity during visits, the necessity for long-term follow-up, and testing for the effectiveness of varied and flexible visit schedules/content focus for women and families with trauma exposure.

Correction to: What's Happening During Home Visits? Exploring the Relationship of Home Visiting Content and Dosage to Parenting Outcomes.

The article "What's Happening During Home Visits? Exploring the Relationship of Home Visiting Content and Dosage to Parenting Outcomes", written by Peggy Nygren, Beth Green, Katie Winters and Anna Rockhill, was originally published electronically on the publisher's internet portal (currently SpringerLink) on 13 June 2018 without open access.

It's not as simple as it sounds: Problems and solutions in accessing and using administrative child welfare data for evaluating the impact of early childhood interventions.

In recent years, there has been increasing interest in using administrative data collected by state child welfare agencies as a source of information for research and evaluation. The challenges of obtaining access to and using these data, however, have not been well documented. This study describes the processes used to access child welfare records in six different states and the approach to combining and using the information gathered to evaluate the impact of the Early Head Start program on children's involvement with the child welfare system from birth through age eleven. We provide "lessons learned" for researchers who are attempting to use this information, including being prepared for long delays in access to information, the need for deep understanding of how child welfare agencies record and code information, and for considerable data management work for translating agency records into analysis-ready datasets. While accessing and using this information is not easy, and the data have a number of limitations, we suggest that the benefits can outweigh the challenges and that these records can be a useful source of information for policy-relevant child welfare research.

Systematic review: comparative effectiveness of medications to reduce risk for primary breast cancer.

BACKGROUND: Trials demonstrate the efficacy of medications to reduce the risk for invasive breast cancer. PURPOSE: To summarize benefits and harms of tamoxifen citrate, raloxifene, and tibolone to reduce the risk for primary breast cancer. DATA SOURCES: MEDLINE and Cochrane databases from inception to January 2009, Web of Science, trial registries, and manufacturer information. STUDY SELECTION: Predefined eligibility criteria were used to select articles. English-language reports of randomized, controlled trials (RCTs) for benefits and RCTs and observational studies for harms were included. DATA EXTRACTION: Two reviewers assessed study data, quality, and applicability. DATA SYNTHESIS: Seven placebo-controlled RCTs and 1 head-to-head trial provide results for main outcomes. Tamoxifen (risk ratio, 0.70 [95% CI, 0.59 to 0.82]; 4 trials), raloxifene (risk ratio, 0.44 [CI, 0.27 to 0.71]; 2 trials), and tibolone (risk ratio, 0.32 [CI, 0.13 to 0.80]; 1 trial) reduce risk for invasive breast cancer compared with placebo by 7 to 10 per 1000 women per year. Tamoxifen and raloxifene reduce estrogen receptor-positive breast cancer but not estrogen receptor-negative breast cancer, noninvasive breast cancer, or mortality. All medications reduce fractures. Tamoxifen (risk ratio, 1.93 [CI, 1.41 to 2.64]; 4 trials) and raloxifene (risk ratio, 1.60 [CI, 1.15 to 2.23]; 2 trials) increase thromboembolic events by 4 to 7 per 1000 women per year; raloxifene causes fewer events than tamoxifen. Tamoxifen increases risk for endometrial cancer (risk ratio, 2.13 [CI, 1.36 to 3.32]; 3 trials) compared with placebo by 4 per 1000 women per year and causes cataracts compared with raloxifene. Tibolone causes strokes in older women. LIMITATIONS: Bias, trial heterogeneity, and a dearth of head-to-head trials limit this review. Data are lacking on doses, duration, and timing of the medications; long-term effects; and nonwhite and premenopausal women. CONCLUSION: Three medications reduce risk for primary breast cancer but increase risk for thromboembolic events (tamoxifen, raloxifene), endometrial cancer (tamoxifen), or stroke (tibolone).

Evidence on the benefits and harms of screening and treating pregnant women who are asymptomatic for bacterial vaginosis: an update review for the U.S. Preventive Services Task Force.

BACKGROUND: Bacterial vaginosis is the most common lower genital tract syndrome among women of reproductive age. There has been continued debate about the value of screening and treating asymptomatic pregnant women for bacterial vaginosis. PURPOSE: To examine new evidence on the benefits and harms of screening and treating bacterial vaginosis in asymptomatic pregnant women. DATA SOURCES: English-language studies on Ovid MEDLINE (2000 to September 2007) and Cochrane Library databases (through September 2007), reference lists, and expert suggestions. STUDY SELECTION: Screening, treatment, or adverse effect studies with pregnancy outcome data in women who are asymptomatic for bacterial vaginosis. DATA EXTRACTION: Study and patient characteristics, treatment variables, adverse pregnancy outcomes, and internal validity quality criteria from the U.S. Preventive Services Task Force (USPSTF) and Jadad scale were abstracted. DATA SYNTHESIS: 7 new randomized, controlled treatment trials and 2001 report data were combined in a series of meta-analyses to estimate the pooled effect of treatment on preterm delivery (<37, <34, and <32 weeks); low birthweight; and preterm, premature rupture of membranes. LIMITATIONS: No screening studies that compared a screened population with a nonscreened population were found. Significant heterogeneity was found among the high-risk treatment trials (P < 0.001). It is not clear from the detailed description of the studies which factors explain the differences in preterm delivery rates and potentially the association of treatment effect; however, both raise concern for the unintended potential for harm. CONCLUSION: No benefit was found in treating women with low- or average-risk pregnancies for asymptomatic bacterial vaginosis. More research is needed to better understand these groups and the conditions under which treatment can be harmful or helpful, and to explore the relevance of bacterial vaginosis to other adverse pregnancy outcomes, such as delivery before 34 weeks.

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.

Physicians, patients, and the electronic health record: an ethnographic analysis.

PURPOSE: Little is known about the effects of the electronic health record (EHR) on physician-patient encounters. The objectives of this study were to identify the factors that influence the manner by which physicians use the EHR with patients. METHODS: This ethnographic study included 4 qualitative components: 80 hours of participant observation in 4 primary care offices in the Pacific Northwest; individual interviews with 52 patients, 12 office staff members, 23 physicians, and 1 nurse-practitioner; videotaped reviews of 29 clinical encounters; and 5 focus-group interviews with physicians and computer advocates. The main outcome measures were factors that influence how physicians use the EHR. Researchers qualitatively derived these factors through serial reviews of data. RESULTS: This study identified 14 factors that influence how EHRs are used and perceived in medical practice today. These factors were categorized into 4 thematic domains: (1) spatial--effect of the physical presence and location of EHRs on interactions between physicians and patients; (2) relational--perceptions of physicians and patients about the EHR and how those perceptions affected its use; (3) educational--issues of developing physicians' proficiency with and improving patients' understandings about EHR use; and (4) structural--institutional and technological forces that influence how physicians perceived their use of EHR. CONCLUSIONS: This study found that the introduction of EHRs into practice influences multiple cognitive and social dimensions of the clinical encounter. It brings into focus important questions that through further inquiry can determine how to make best use of the EHR to enhance therapeutic relationships.

Predicting Positive Education Outcomes for Emerging Adults in Mental Health Systems of Care.

Emerging adults who receive services based on positive youth development models have shown an ability to shape their own life course to achieve positive goals. This paper reports secondary data analysis from the Longitudinal Child and Family Outcome Study including 248 culturally diverse youth ages 17 through 22 receiving mental health services in systems of care. After 12 months of services, school performance was positively related to youth ratings of school functioning and service participation and satisfaction. Regression analysis revealed ratings of young peoples' perceptions of school functioning, and their experience in services added to the significant prediction of satisfactory school performance, even controlling for sex and attendance. Finally, in addition to expected predictors, participation in planning their own services significantly predicted enrollment in higher education for those who finished high school. Findings suggest that programs and practices based on positive youth development approaches can improve educational outcomes for emerging adults.

Screening women and elderly adults for family and intimate partner violence: a review of the evidence for the U. S. Preventive Services Task Force.

BACKGROUND: Family and intimate partner violence is common in the United States and is often associated with acute and chronic health problems. Although the clinician's role in identification and intervention is considered a professional, ethical, and sometimes legal responsibility, the effectiveness of screening is uncertain. PURPOSE: To examine evidence on the benefits and harms of screening women and elderly adults in health care settings for family and intimate partner violence. DATA SOURCES: MEDLINE, PsycINFO, CINAHL, Health & Psychosocial Instruments, AARP Ageline, Cochrane Controlled Trials Register, reference lists, and experts. STUDY SELECTION: The authors selected English-language studies that included original data focusing on the performance of screening instruments (14 studies for women, 3 for elderly persons) and the effectiveness of interventions based in health care settings (2 studies for women, none for elderly persons). DATA EXTRACTION: Study design, patient samples and settings, methods of assessment or intervention, and outcome measures were extracted, and a set of criteria was applied to evaluate study quality. DATA SYNTHESIS: No trials of the effectiveness of screening in a health care setting for reducing harm have been published. Several screening instruments have been developed; some have demonstrated fair to good internal consistency and some have been validated with longer instruments, but none have been evaluated against measurable violence or health outcomes. Few intervention studies have been conducted. Existing intervention studies focused on pregnant women, and study limitations restrict their interpretation. CONCLUSION: Although the literature on family and intimate partner violence is extensive, few studies provide data on detection and management to guide clinicians.

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.

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.

Universal newborn hearing screening: systematic review to update the 2001 US Preventive Services Task Force Recommendation.

OBJECTIVE: This review is an update for the US Preventive Services Task Force on universal newborn hearing screening to detect moderate-to-severe permanent, bilateral congenital hearing loss. We focus on 3 key questions: (1) Among infants identified by universal screening who would not be identified by targeted screening, does initiating treatment before 6 months of age improve language and communication outcomes? (2) Compared with targeted screening, does universal screening increase the chance that treatment will be initiated by 6 months of age for infants at average risk or for those at high risk? (3) What are the adverse effects of screening and early treatment? METHODS: Medline and Cochrane databases were searched to identify articles published since the 2002 recommendation. Data from studies that met inclusion criteria were abstracted, and studies were rated for quality with predetermined criteria. RESULTS: A good-quality retrospective study of children with hearing loss indicates that those who had early versus late confirmation and those who had undergone universal newborn screening versus none had better receptive language at 8 years of age but not better expressive language or speech. A good-quality nonrandomized trial of a large birth cohort indicates that infants identified with hearing loss through universal newborn screening have earlier referral, diagnosis, and treatment than those not screened. These findings are corroborated by multiple descriptive studies of ages of referral, diagnosis, and treatment. Usual parental reactions to an initial nonpass on a hearing screen include worry, questioning, and distress that resolve for most parents. Cochlear implants have been associated with higher risks for bacterial meningitis in young children. CONCLUSIONS: Children with hearing loss who had universal newborn hearing screening have better language outcomes at school age than those not screened. Infants identified with hearing loss through universal screening have significantly earlier referral, diagnosis, and treatment than those identified in other ways.

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.

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.

Screening for elevated lead levels in childhood and pregnancy: an updated summary of evidence for the US Preventive Services Task Force.

BACKGROUND: In 1996, the US Preventive Services Task Force provided recommendations for routine screening of asymptomatic children and pregnant women for elevated blood lead levels. This review updates the evidence for the benefits and harms of screening and intervention for elevated blood lead in asymptomatic children and pregnant women. METHODS: We searched Medline, reference lists of review articles, and tables of contents of leading pediatric journals for studies published in 1995 or later that contained new information about the prevalence, diagnosis, natural course, or treatment of elevated lead levels in asymptomatic children aged 1 to 5 years and pregnant women. RESULTS: The prevalence of elevated blood lead levels among children and women in the United States, like that in the general population, continues to decline sharply, primarily because of marked reductions in environmental exposure, but still varies substantially among different communities and populations. Similar to the findings in 1996, our searches did not identify direct evidence from controlled studies that screening children for elevated blood lead levels results in improved health outcomes, and there was no direct evidence identified from controlled studies that screening improves pregnancy or perinatal outcomes. No new relevant information regarding the accuracy of screening for lead toxicity was identified during the update, and we did not identify evidence that demonstrates that universal screening for blood lead results in better clinical outcomes than targeted screening. Substantial new relevant information regarding the adverse effects of screening and interventions was not identified. CONCLUSIONS: There is no persuasive evidence that screening for elevated lead levels in asymptomatic children will improve clinical outcomes. For those children who are screened and found to have elevated levels, there is conflicting evidence demonstrating the clinical effectiveness of early detection and intervention.

Screening children for family violence: a review of the evidence for the US Preventive Services Task Force.

BACKGROUND: We wanted to evaluate the benefits and harms of screening children in primary health care settings for abuse and neglect resulting from family violence by examining the evidence on the performance of screening instruments and the effectiveness of interventions. METHODS: We searched for relevant studies in MEDLINE, PsycINFO, CINAHL, ERIC, Cochrane Controlled Trials Register, and reference lists. English language abstracts with original data about family violence against children focusing on screening and interventions initiated or based in health care settings were included. We extracted selected information about study design, patient populations and settings, methods of assessment or intervention, and outcome measures, and applied a set of criteria to evaluate study quality. RESULTS: All instruments designed to screen for child abuse and neglect were directed to parents, particularly pregnant women. These instruments had fairly high sensitivity but low specificity when administered in high-risk study populations and have not been widely tested in other populations. Randomized controlled trials of frequent nurse home visitation programs beginning during pregnancy that address behavioral and psychological factors indicated improved abuse measures and outcomes. No studies were identified about interventions in older children or harms associated with screening and intervention. CONCLUSIONS: No trials of the effectiveness of screening in a health care setting have been published. Clinician referrals to nurse home visitation during pregnancy and in early childhood may reduce abuse in selected populations. There are no studies about harms of screening and interventions.

Predicting vaginal birth after cesarean delivery: a review of prognostic factors and screening tools.

OBJECTIVE: Our purpose was to identify the factors associated with vaginal delivery after trial of labor in patients with a prior cesarean and to evaluate the effectiveness of existing screening tools. STUDY DESIGN: Studies were identified through MEDLINE and HealthSTAR (1980-2002), reference list reviews, and suggestions of national experts. RESULTS: Thirteen of the 100 eligible studies provided fair to good quality evidence for the predictive nature of 12 factors. Two of the six screening tools were considered promising and demonstrated reproducibility through validation studies. CONCLUSIONS: There is little high-quality data to guide clinical decisions regarding which women are likely to have a successful trial of labor. Although we identified two validated screening tools that may be reasonable for practitioners to use, further development is needed to deliver them in a user-friendly manner and further research is needed to determine the clinical setting in which they are most useful. Conducting high-quality research on the factors that delineate women who are at higher likelihood of vaginal delivery without complications and developing accurate user-friendly screening tools to integrate these data should be a national research priority.

Childbirth preferences after cesarean birth: a review of the evidence.

BACKGROUND: Conflicting evidence on maternal and fetal safety of vaginal and cesarean childbirth after a previous cesarean makes patients and practitioners uncertain about pursuing a trial of labor or an elective repeat cesarean delivery. This review systematically evaluated and summarized the evidence related to women's preference for delivery. METHODS: The Cochrane Database of Systematic Reviews and Registry of Controlled Trials and the MEDLINE, HealthSTAR, PsycINFO, and CINAHL databases were searched from 1980 to August 2002. We reviewed controlled trials, case-control studies, and observational studies that contained original patient data on preference for women with a previous cesarean delivery and that were of "good" or "fair" quality. RESULTS: Women with a previous vaginal delivery were more likely to select trial of labor than women who did not have one. The most commonly cited reason for selecting trial of labor was ease of recovery and desire to return quickly to caring for other children (reported in 6 of 7 studies). Safety for the mother and/or infant was cited as an important reason for delivery choice in 4 of 11 studies. Important ethnic differences were reported. Nonwhite women were more likely to identify their provider as an important influence (39% vs 19%), and perceived labor as something to be avoided if another option resulted in a healthy baby compared with white women, who perceived labor as a challenge and an experience not to be missed. CONCLUSIONS: A woman's choice for delivery was often based on family obligations, such as the need for a shorter recovery so that she could care for her infant and children at home, rather than the safety of herself or her infant. It remains unclear if education on vaginal birth after cesarean increases the proportion of women who choose trial of labor. Future studies should evaluate the impact of education and timing of education on patient preference.

Postmenopausal hormone replacement therapy: scientific review.

CONTEXT: Although postmenopausal hormone replacement therapy (HRT) is widely used in the United States, new evidence about its benefits and harms requires reconsideration of its use for the primary prevention of chronic conditions. OBJECTIVE: To assess the benefits and harms of HRT for the primary prevention of cardiovascular disease, thromboembolism, osteoporosis, cancer, dementia, and cholecystitis by reviewing the literature, conducting meta-analyses, and calculating outcome rates. DATA SOURCES: All relevant English-language studies were identified in MEDLINE (1966-2001), HealthSTAR (1975-2001), Cochrane Library databases, and reference lists of key articles. Recent results of the Women's Health Initiative (WHI) and the Heart and Estrogen/progestin Replacement Study (HERS) are included for reported outcomes. STUDY SELECTION AND DATA EXTRACTION: We used all published studies of HRT if they contained a comparison group of HRT nonusers and reported data relating to HRT use and clinical outcomes of interest. Studies were excluded if the population was selected according to prior events or presence of conditions associated with higher risks for targeted outcomes. DATA SYNTHESIS: Meta-analyses of observational studies indicated summary relative risks (RRs) for coronary heart disease (CHD) incidence and mortality that were significantly reduced among current HRT users only, although risk for incidence was not reduced when only studies that controlled for socioeconomic status were included. The WHI reported increased CHD events (hazard ratio [HR], 1.29; 95% confidence interval [CI], 1.02-1.63). Stroke incidence but not mortality was significantly increased among HRT users in the meta-analysis and the WHI. The meta-analysis indicated that risk was significantly elevated for thromboembolic stroke (RR, 1.20; 95% CI, 1.01-1.40) but not subarachnoid or intracerebral stroke. Risk of venous thromboembolism among current HRT users was increased overall (RR, 2.14; 95% CI, 1.64-2.81) and was highest during the first year of use (RR, 3.49; 95% CI, 2.33-5.59) according to a meta-analysis of 12 studies. Protection against osteoporotic fractures is supported by a meta-analysis of 22 estrogen trials, cohort studies, results of the WHI, and trials with bone density outcomes. Current estrogen users have an increased risk of breast cancer that increases with duration of use. Endometrial cancer incidence, but not mortality, is increased with unopposed estrogen use but not with estrogen with progestin. A meta-analysis of 18 observational studies showed a 20% reduction in colon cancer incidence among women who had ever used HRT (RR, 0.80; 95% CI, 0.74-0.86), a finding supported by the WHI. Women symptomatic from menopause had improvement in certain aspects of cognition. Current studies of estrogen and dementia are not definitive. In a cohort study, current HRT users had an age-adjusted RR for cholecystitis of 1.8 (95% CI, 1.6-2.0), increasing to 2.5 (95% CI, 2.0-2.9) after 5 years of use. CONCLUSIONS: Benefits of HRT include prevention of osteoporotic fractures and colorectal cancer, while prevention of dementia is uncertain. Harms include CHD, stroke, thromboembolic events, breast cancer with 5 or more years of use, and cholecystitis.

Systematic review of the incidence and consequences of uterine rupture in women with previous caesarean section.

OBJECTIVE: To evaluate the incidence and consequences of uterine rupture in women who have had a delivery by caesarean section. DESIGN: Systematic review. DATA SOURCES: Medline, HealthSTAR, Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, National Centre for Reviews and Dissemination, reference lists, and national experts. Studies in all languages were eligible if published in full. REVIEW METHODS: Methodological quality was evaluated for each study by using criteria from the United States Preventive Services Task Force and the National Health Service Centre for Reviews and Dissemination. Uterine rupture was categorised as asymptomatic or symptomatic. RESULTS: We reviewed 568 full text articles to identify 71 potentially eligible studies, 21 of which were rated at least fair in quality. Compared with elective repeat caesarean delivery, trial of labour increased the risk of uterine rupture by 2.7 (95% confidence interval 0.73 to 4.73) per 1000 cases. No maternal deaths were related to rupture. For women attempting vaginal delivery, the additional risk of perinatal death from rupture of a uterine scar was 1.4 (0 to 9.8) per 10,000 and the additional risk of hysterectomy was 3.4 (0 to 12.6) per 10 000. The rates of asymptomatic uterine rupture in trial of labour and elective repeat caesarean did not differ significantly. CONCLUSIONS: Although the literature on uterine rupture is imprecise and inconsistent, existing studies indicate that 370 (213 to 1370) elective caesarean deliveries would need to be performed to prevent one symptomatic uterine rupture.