Examining gender differences in adolescent exposure to food and beverage marketing through go-along interviews.

This study explores how adolescents engage with unhealthy food and beverage marketing in online settings, from a gender perspective. Employing an online ethnography approach and using go-along interviews, we explored the experiences of adolescent boys and girls aged 13-17 as they navigated their online experiences with digital food and beverage marketing. Notable themes emerged, including the identification of predatory actions by food companies, the role of protective factors such as family, and the influence of social media influencers in shaping adolescent dietary preferences. Importantly, this research unearthed gender disparities in the participants' responses. Girls, in particular, exhibited a heightened awareness of the protective role played by their families, emphasized the influence of color in marketing strategies, recognized the significance of gender in marketing, and reported exposure to alcohol advertisements-findings that boys less frequently echoed. The study underscores the importance of adolescence as a critical phase in development, during which food companies target these impressionable individuals, driven by their independence and potential for brand loyalty. Moreover, it highlights the potential avenue of gender-specific marketing, offering valuable insights into the gendered dimensions of adolescents' food marketing experiences. By examining the interplay between digital food marketing and gender, this research addresses a critical gap in the literature, shedding light on how gender influences adolescents' perceptions, responses, and behaviors in the context of food marketing strategies. These findings have the potential to inform adolescents of the marketing techniques that target them and guide policymakers in developing and implementing evidence-based regulations aimed at safeguarding adolescents from exposure to unhealthy food marketing.

Realist review to understand the efficacy of culturally appropriate diabetes education programmes.

AIMS: Minority populations often face linguistic, cultural and financial barriers to diabetes education and care. The aim was to understand why culturally appropriate diabetes education interventions work, when they work best and for whom they are most effective. METHODS: This review used a critical realist approach to examine culturally appropriate diabetes interventions. Beginning with the behavioural model and access to medical care, it reanalysed 11 randomized controlled trials from a Cochrane systematic review and related programme and training documents on culturally appropriate diabetes interventions. The analysis examined context and mechanism to understand their relationship to participant retention and statistically improved outcomes. RESULTS: Minority patients with language barriers and limited access to diabetes programmes responded to interventions using health workers from the same ethnic group and interventions promoting culturally acceptable and financially affordable food choices using local ingredients. Programme incentives improved retention in the programmes and this was associated with improved HbA(1c) levels at least in the short term. Adopting a positive learning environment, a flexible and less intensive approach, one-to-one teaching in informal settings compared with a group approach in clinics led to improved retention rates. CONCLUSIONS: Minority and uninsured migrants with unmet health needs showed the highest participation and HbA(1c) responses from culturally appropriate programmes.

Risk-adjusted relationship between voriconazole utilization and non-melanoma skin cancer among lung and heart/lung transplant patients.

BACKGROUND: We examined the relationship between voriconazole utilization and non-melanoma skin cancer (NMSC) development among adult lung and heart/lung transplant patients who were continuously enrolled in a large U.S. commercial health plan. METHODS: Cox proportional hazards regression models were constructed to assess both the crude and adjusted effect of voriconazole usage on NMSC development. Overall, 467 adult lung (98%) and heart/lung (2%) transplant patients (60% male) with median age of 58 years were analyzed. RESULTS: Fifty-seven (12%) patients developed NMSC over a median follow-up time of 610 days. At the crude level, patients with any (vs. none) claim for voriconazole were more likely to develop NMSC (19% vs. 12%, hazard ratio [HR]: 1.74, 95% confidence interval [CI]: 1.02, 2.96, P = 0.04). However, after statistical adjustment for demographic and clinical factors, the effect was largely diminished and no longer statistically significant (HR: 1.23, 95% CI: 0.71, 2.14, P = 0.45). Results were similar when modeling average and total dose of voriconazole. Risk factors significantly related to NMSC development were being male, older age, sun exposure, history of chronic obstructive pulmonary disorder, and history of immune disorder. CONCLUSION: Results suggest that the relationship between voriconazole utilization and NMSC among lung transplant patients may be a result of confounding by indication, and that controlling for underlying patient characteristics is paramount.

Using direct payments to fund short breaks for families with a disabled child.

BACKGROUND: A clear policy trend exists towards promoting the use of direct payments (DPs), including those for families with disabled children who use short breaks. However, uptake has been slow and use of DPs has been socially patterned. Recent programmes in England have dramatically increased investment in short break provision including breaks funded through DPs. This research examines the characteristics, circumstances and experiences of families who use DPs to fund short breaks with those who use short breaks funded in other ways. METHOD: The paper draws on surveys totalling 348 parents and carers in families with disabled children using short breaks. We investigate associations between the use of DPs and a range of demographic, socio-economic, well-being, service use and satisfaction indicators. Logistic regression identifies which variables are most strongly associated with use of DPs. We also draw on open-ended survey responses which highlight important aspects of families' experience of using DPs. RESULTS: Characteristics significantly associated with increased use of DPs include the presence of main carers who are female, more highly educated and from White British backgrounds, younger children, lower levels of area deprivation, greater access to service and social networks and use of more hours of short breaks. Characteristics not found to be significantly associated with use of DPs include various health and well-being indicators, impairment characteristics of children and service satisfaction. A range of benefits of DPs are described along with problems accessing and using them. CONCLUSIONS: Direct payments can have a number of benefits for families using short breaks, but access to them is currently problematic and socially patterned. If the uptake of DPs is to be increased and made more equitable, more attention must be paid to promoting and supporting their use in ways which meet the needs of individual families.

Sex and Gender Appraisal Tool-Systematic Reviews-2 and Participation-To-Prevalence Ratio assessed to whom the evidence applies in sepsis reviews.

OBJECTIVES: To revise a sex and gender appraisal tool for systematic reviews (SGAT-SR) and apply it to Cochrane sepsis reviews. STUDY DESIGN AND SETTING: The revision process was informed by existing literature on sex, gender, intersectionality, and feedback from an expert advisory board. We revised the items to consider additional factors associated with health inequities and appraised sex and gender considerations using the SGAT-SR-2 and female Participation-to-Prevalence Ratio (PPR) in Cochrane sepsis reviews. RESULTS: SGAT-SR-2 consists of 19 questions appraising the review's sections and use of the terms sex and gender. amongst 71 SRs assessed, 50.7% included at least one tool item, the most frequent being the number of participants by sex or gender at included study-level (24/71 reviews). Only four reviews provided disaggregated data for the full set of included trials, while two considered other equity-related factors. Reviews rarely appraised possible similarities and differences across sex and gender. In half of a subset of reviews, female participants were under-represented relative to their share of the sepsis population (PPR<0.8). CONCLUSION: The SGAT-SR-2 tool and the PPR can support the design and appraisal of systematic reviews to assess sex and gender considerations, address to whom evidence applies, and determine future research needs.

Grading quality of evidence and strength of recommendations in clinical practice guidelines part 3 of 3. The GRADE approach to developing recommendations.

This is the third and last article in the series about the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to grading the quality of evidence and the strength of recommendations in clinical practice guidelines and its application in the field of allergy. We describe the factors that influence the strength of recommendations about the use of diagnostic, preventive and therapeutic interventions: the balance of desirable and undesirable consequences, the quality of a body of evidence related to a decision, patients' values and preferences, and considerations of resource use. We provide examples from two recently developed guidelines in the field of allergy that applied the GRADE approach. The main advantages of this approach are the focus on patient important outcomes, explicit consideration of patients' values and preferences, the systematic approach to collecting the evidence, the clear separation of the concepts of quality of evidence and strength of recommendations, and transparent reporting of the decision process. The focus on transparency facilitates understanding and implementation and should empower patients, clinicians and other health care professionals to make informed choices.

Mass deworming for soil-transmitted helminths and schistosomiasis among pregnant women: A systematic review and individual participant data meta-analysis.

The objective of the review is to use individual participant data (IPD) meta-analysis to explore the effect of mass deworming during pregnancy. We developed a search strategy and searched the databases till March 2018. We included individually randomised controlled trials; cluster randomised controlled trials and quasi randomised studies providing preventive or therapeutic deworming drugs for soil transmitted helminthiases and schistosomiasis during pregnancy. All IPD were assessed for completeness, compared to published reports and entered into a common data spreadsheet. Out of the seven trials elgible for IPD, we received data from three trials; out of 8,515 potential IPD participants; data were captured for 5,957 participants. Findings from this IPD suggest that mass deworming during pregnancy reduces maternal anaemia by 23% (Risk ratio [RR]: 0.77, 95% confidence intreval [CI]: 0.73-0.81; three trials; 5,216 participants; moderate quality evidence). We did not find any evidence of an effect of mass deworming during pregnancy on any of the other outcomes. There was no evidence of effect modification; however these findings should be interpreted with caution due to small sample sizes. The quality of evidence was rated as moderate for our findings. Our analyses suggest that mass deworming during pregnancy is associated with reducing anaemia with no evidence of impact on any other maternal or pregnancy outcomes. Our analyses were limited by the availability of data for the impact by subgroups and effect modification. There is also a need to support and promote open data for future IPDs.

Reporting of sex and gender in randomized controlled trials in Canada: a cross-sectional methods study.

BACKGROUND: Accurate reporting on sex and gender in health research is integral to ensuring that health interventions are safe and effective. In Canada and internationally, governments, research organizations, journal editors, and health agencies have called for more inclusive research, provision of sex-disaggregated data, and the integration of sex and gender analysis throughout the research process. Sex and gender analysis is generally defined as an approach for considering how and why different subpopulations (e.g., of diverse genders, ages, and social locations) may experience health conditions and interventions in different or similar ways.The objective of this study was to assess the extent and nature of reporting about sex and/or gender, including whether sex and gender analysis (SGA) was carried out in a sample of Canadian randomized controlled trials (RCTs) with human participants. METHODS: We searched MEDLINE from 01 January 2013 to 23 July 2014 using a validated filter for identification of RCTs, combined with terms related to Canada. Two reviewers screened the search results to identify the first 100 RCTs that were either identified in the trial publication as funded by a Canadian organization or which had a first or last author based in Canada. Data were independently extracted by two people from 10% of the RCTs during an initial training period; once agreement was reached on this sample, the remainder of the data extraction was completed by one person and verified by a second. RESULTS: The search yielded 1433 records. We screened 256 records to identify 100 RCTs which met our eligibility criteria. The median sample size of the RCTs was 107 participants (range 12-6085). While 98% of studies described the demographic composition of their participants by sex, only 6% conducted a subgroup analysis across sex and 4% reported sex-disaggregated data. No article defined "sex" and/or "gender." No publication carried out a comprehensive sex and gender analysis. CONCLUSIONS: Findings highlight poor uptake of sex and gender considerations in the Canadian RCT context and underscore the need for better articulated guidance on sex and gender analysis to improve reporting of evidence, inform policy development, and guide future research.

When is a randomised controlled trial health equity relevant? Development and validation of a conceptual framework.

BACKGROUND: Randomised controlled trials can provide evidence relevant to assessing the equity impact of an intervention, but such information is often poorly reported. We describe a conceptual framework to identify health equity-relevant randomised trials with the aim of improving the design and reporting of such trials. METHODS: An interdisciplinary and international research team engaged in an iterative consensus building process to develop and refine the conceptual framework via face-to-face meetings, teleconferences and email correspondence, including findings from a validation exercise whereby two independent reviewers used the emerging framework to classify a sample of randomised trials. RESULTS: A randomised trial can usefully be classified as 'health equity relevant' if it assesses the effects of an intervention on the health or its determinants of either individuals or a population who experience ill health due to disadvantage defined across one or more social determinants of health. Health equity-relevant randomised trials can either exclusively focus on a single population or collect data potentially useful for assessing differential effects of the intervention across multiple populations experiencing different levels or types of social disadvantage. Trials that are not classified as 'health equity relevant' may nevertheless provide information that is indirectly relevant to assessing equity impact, including information about individual level variation unrelated to social disadvantage and potentially useful in secondary modelling studies. CONCLUSION: The conceptual framework may be used to design and report randomised trials. The framework could also be used for other study designs to contribute to the evidence base for improved health equity.

Color-selecting reflectors inspired from biological periodic multilayer structures.

We propose a semi-infinite 1-D photonic crystal approach for designing artificial reflectors which aim to reproduce color changes with the angle of incidence found in biological periodic multilayer templates. We show that both the dominant reflected wavelength and the photonic bandgap can be predicted and that these predictions agree with exact calculations of reflectance spectra for a finite multilayer structure. In order to help the designer, the concept of spectral richness of angle-tuned color-selecting reflectors is introduced and color changes with angle are displayed in a chromaticity diagram. The usefulness of the photonic crystal approach is demonstrated by modelling a biological template (found in the cuticle of Chrysochora vittata beetle) and by designing a bio-inspired artificial reflector which reproduces the visual aspect of the template. The bioinspired novel aspect of the design relies on the strong unbalance between the thicknesses of the two layers forming the unit cell.

Interactive social media interventions to promote health equity: an overview of reviews.

INTRODUCTION: Social media use has been increasing in public health and health promotion because it can remove geographic and physical access barriers. However, these interventions also have the potential to increase health inequities for people who do not have access to or do not use social media. In this paper, we aim to assess the effects of interactive social media interventions on health outcomes, behaviour change and health equity. METHODS: We conducted a rapid response overview of systematic reviews. We used a sensitive search strategy to identify systematic reviews and included those that focussed on interventions allowing two-way interaction such as discussion forums, social networks (e.g. Facebook and Twitter), blogging, applications linked to online communities and media sharing. RESULTS: Eleven systematic reviews met our inclusion criteria. Most interventions addressed by the reviews included online discussion boards or similar strategies, either as stand-alone interventions or in combination with other interventions. Seven reviews reported mixed effects on health outcomes and healthy behaviours. We did not find disaggregated analyses across characteristics associated with disadvantage, such as lower socioeconomic status or age. However, some targeted studies reported that social media interventions were effective in specific populations in terms of age, socioeconomic status, ethnicities and place of residence. Four reviews reported qualitative benefits such as satisfaction, finding information and improved social support. CONCLUSION: Social media interventions were effective in certain populations at risk for disadvantage (youth, older adults, low socioeconomic status, rural), which indicates that these interventions may be effective for promoting health equity. However, confirmation of effectiveness would require further study. Several reviews raised the issue of acceptability of social media interventions. Only four studies reported on the level of intervention use and all of these reported low use. More research on established social media platforms with existing social networks is needed, particularly in populations at risk for disadvantage, to assess effects on health outcomes and health equity.

TITRE: Interventions interactives dans les médias sociaux visant à promouvoir l'équité en matière de santé : vue d'ensemble des examens. INTRODUCTION: L'utilisation des médias sociaux en matière de santé publique et de promotion de la santé est en croissance, car ces outils permettent d'éliminer les barrières géographiques et physiques à l'accès aux services et aux soins de santé. Cependant, ils sont une source potentielle d'inégalité en matière de santé car une partie de la population n'y a pas accès ou ne les utilise pas. Cet article a comme objectif d'évaluer les effets des interventions interactives dans les médias sociaux sur les résultats sanitaires, les changements de comportement et l'équité en matière de santé. MÉTHODOLOGIE: Nous avons réalisé une synthèse rapide d'examens systématiques axés sur des interventions favorables aux interactions réciproques, que ce soit les forums de discussion, les réseaux sociaux (comme Facebook et Twitter), les blogues, les applications liées aux communautés électroniques ou le partage de contenu multimédia. Nous avons eu recours à une stratégie de recherche fine pour sélectionner les examens systématiques. RÉSULTATS: Onze examens systématiques ont répondu à nos critères d'inclusion. La plupart des interventions visées par ces examens visaient des groupes de discussion en ligne ou des outils similaires. Ces interventions étaient isolées ou conjointes à d'autres. Sept examens ont fait état d'effets mixtes sur les résultats sanitaires et les comportements sains. On n'a constaté aucune analyse détaillée des caractéristiques liées aux inconvénients, notamment un statut socioéconomique plus faible ou l'âge. Par contre, certaines études ciblées ont montré que les interventions dans les médias sociaux étaient efficaces pour certaines populations précises sur le plan de l'âge, du statut socioéconomique, de l'ethnicité et du lieu de résidence. Quatre examens ont fait état d'avantages qualitatifs, comme la satisfaction, le recueil d'information et l'amélioration du soutien social. CONCLUSION : Les interventions dans les médias sociaux se sont avérées efficaces pour certaines populations susceptibles d'être désavantagées (jeunes, aînés, personnes à faible statut socioéconomique et population rurale), ce qui prouve leur efficacité potentielle pour l'avancement de l'équité en matière de santé. La confirmation de cette efficacité nécessiterait toutefois une étude approfondie. Plusieurs examens ont soulevé la question de l'acceptabilité des interventions dans les médias sociaux. Seulement quatre études se sont penchées sur le niveau d'utilisation de l'intervention et elles ont toutes dévoilé un faible niveau d'utilisation. Il faudra réaliser d'autres travaux de recherche sur les plateformes des principaux médias sociaux actuels, particulièrement auprès des populations risquant d'être désavantagées, afin d'évaluer leurs effets sur les résultats sanitaires et l'équité en matière de santé.

Transport and cellular uptake of polychlorinated biphenyls (PCBs)--I. Association of individual PCB isomers and congeners with plasma lipoproteins and proteins in the pigeon.

Polychlorinated biphenyls (PCBs) are abundant and persistent pollutants in the ecosystem. Commercial mixtures (e.g. Aroclor 1254) can contain up to 80 different isomers and congeners, many of which accumulate in biological systems by the ingestion of PCB-contaminated lipid components of food chains. PCBs are lipophilic and lipid-rich lipoproteins provide an excellent system to transport PCBs to tissues. We report here the distribution of PCBs between plasma fractions in the pigeon. Twenty-four hours after injection, [14C]4-monochlorobiphenyl and [14C]2,2',5,5'-tetrachlorobiphenyl were associated with the protein-rich HDL fraction and the lipoprotein-poor fraction (predominantly albumin), rather than with the lipid-rich VLDL and LDL fractions. Five days after injection with the commercial PCB mixture Aroclor 1254, there was a distinctive distribution between the plasma fractions of the 41 congeners detected. Avian species have a poorly developed lymphatic system and dietary lipids are secreted into the portal vein. To emphasize this route of entry, the lipoprotein particles formed are termed portomicrons rather than chylomicrons. The most striking result was that the lipid-rich portomicron and the VLDL fraction was associated almost exclusively with only one congener (2,2',4,4'5,5'-hexachlorobiphenyl), whereas the other isomers and congeners were distributed amongst the LDL, HDL and the lipoprotein-poor (predominantly albumin) fractions. Thirteen of the congeners detected accounted for 74, 53 and 54%, respectively, of the total amount of PCBs in the LDL, HDL and lipoprotein-poor protein fractions. Five congeners that are highly toxic were enriched in the latter fraction. The distribution of PCBs is more complex than can be explained solely by their solubility in the lipid components of plasma fractions, and may suggest a complex association with apolipoproteins and plasma proteins that are important in transporting PCB to tissues. The identification of individual PCBs in lipoprotein fraction provides evidence for their role in the transport of lipophilic xenobiotics in blood and it is suggested that PCBs associated with lipoproteins are taken up by cells as lipoprotein-PCB complexes.

Transport and cellular uptake of polychlorinated biphenyls (PCBs)--II. Changes in vivo in plasma lipoproteins and proteins of pigeons in response to PCBs, and a proposed model for the transport and cellular uptake of PCBs.

The complex distribution of polychlorinated biphenyl (PCB) isomers and congeners amongst plasma fractions of the pigeon suggests that the lipid and apolipoprotein components of lipoproteins, as well as plasma proteins, may be important in transporting PCBs to tissues (Borlakoglu et al., Biochem. Pharmac. 40, 265 (1990]. Pigeons were injected with the commercial PCB mixture Aroclor 1254 (1.5 mmol/kg body weight). After 120 hr triacylglycerol-like droplets accumulated in hepatocytes ('fatty liver syndrome'), there was proliferation of the hepatic smooth endoplasmic reticulum, and plasma concentrations of triacylglycerol and total cholesterol increased. This was accompanied by significant decreases in plasma concentrations of total protein, total apolipoproteins of the low density lipoprotein (LDL) and the high density lipoprotein (HDL) fractions, and albumin and by a significant increase in that of urea, indicating increased protein breakdown. These results suggest that Aroclor 1254 increased hepatic lipid synthesis, but decreased hepatic production of albumin and apolipoproteins. This would explain the accumulation of triacylglycerol in the liver and the increase in the proportion of triacylglycerol to apolipoprotein in the total lipoproteins. From the evidence presented, a model is proposed based on the association of PCBs with hydrophobic domains of lipids and proteins for the transport of PCBs by plasma fractions, their uptake into cells and intracellular metabolism, and their accumulation in adipose tissue.

Genetic alterations in the development of mammary and prostate cancer in the C3(1)/Tag transgenic mouse model.

We have generated a transgenic mouse model in which female mice develop ductal mammary adenocarcinomas and male mice develop prostatic adenocarcinomas by using a transgene containing the hormone-responsive rat prostatic steroid binding protein 5' flanking region C3(1) fused to the simian virus 40 (SV40) large T antigen. We have identified some genetic alterations during mammary and prostate tumor progression: (i) p53 is functionally inactivated during mammary cancer development without p53 mutations; (ii) Alterations in apoptosis during mammary tumor progression are p53 and bcl-2 independent; (iii) Ha-ras mutations occur early in the development of prostate cancer. This unique animal model offers the opportunity to study multistep tumorigenesis in these organs.

Validation of a short rhythm strip compared to ambulatory ECG monitoring for ventricular ectopy.

Premature ventricular contractions (PVCs) are associated with an increased risk of cardiovascular disease and mortality. Many epidemiologic studies measure a continuous short rhythm strip to ascertain PVCs as a screening tool to identify persons at highest risk. Despite its widespread use in epidemiologic studies, the rhythm strip has not been completely validated. Therefore, a continuous 2-min rhythm strip was measured on 242 consecutive individuals referred for ambulatory ECG monitoring. Prevalence of at least one PVC on the 2-min rhythm strip was compared to a gold standard, the average number of PVCs per hr on ambulatory recording. The prevalence of any PVCs on the 2-min rhythm strip was 19%. As average PVCs per hr increased on the ambulatory ECG recording, sensitivity increased while specificity slowly decreased. Sensitivity ranged from 26-100% and specificity ranged from 81-100% across the distribution of average PVCs per hr on ambulatory monitoring. Area under the receiver operator characteristic (ROC) curve of the 2-min rhythm strip compared to 24-hr results was 0.943. Area under ROC curves were not statistically different (P > 0.05) by age, gender, hypertension status, or history of myocardial infarction. In this clinical population, utilizing the 2-min rhythm strip as an indicator of average PVCs per hr had excellent specificity and moderate to low sensitivity across most of the distribution of average PVCs per hr. The use of a short rhythm strip to detect PVCs may be considered useful in epidemiologic investigations of cardiovascular disease and mortality for detecting high frequency PVCs in populations. The use of a short rhythm strip as a screening tool to detect PVCs in clinical practice is not warranted, based on our findings and the existing literature. However, an awareness that PVCs on a 2-min rhythm strip consistently identify high frequency PVCs on 24-hr recordings should be helpful to clinicians.

Nosocomial mumps: report of an outbreak and its control.

BACKGROUND: Mumps is a relatively uncommon disease in the United States, and nosocomial transmission of mumps is rare. METHODS: When a recently arrived Mexican immigrant became ill with mumps in a pediatric hospital in the United States, control measures and careful secondary case surveillance were instituted. Outbreak control included isolation of the patient with symptoms, seclusion of patients potentially incubating mumps virus, and immunization of susceptible patients and health care workers. RESULTS: A 3-year-old patient showed symptoms of mumps 18 days after onset of illness in the index patient. Two employees, a physical therapist and a nurse, became ill with mumps 20 and 28 days after the onset of illness in the index patient. No other hospital or community cases of mumps were identified. CONCLUSIONS: Outbreak control measures were incompletely successful in stopping the spread of mumps. Preadmission immunization of all patients and mumps-specific screening and vaccination of hospital employees might be indicated in such a situation, but such measures are neither easy nor inexpensive.

Cost effectiveness of nasal calcitonin in postmenopausal women: use of Cochrane Collaboration methods for meta-analysis within economic evaluation.

OBJECTIVE: To assess the cost effectiveness of nasal calcitonin (Miacalcin) compared with no therapy, alendronate or etidronate in the treatment of postmenopausal women with previous osteoporotic fracture. DESIGN AND SETTING: Meta-analysis followed by economic analysis. PERSPECTIVE: A Canadian provincial Ministry of Health. METHODS: The meta-analysis of randomised controlled clinical trials was based on the recommendations of the Cochrane Collaboration. Economic analysis was conducted within a Markov model using probabilities and costs derived from Canadian sources. RESULTS: The meta-analysis found evidence of the positive effect of both nasal calcitonin and alendronate in reducing the risks of hip, wrist and vertebral fractures in postmenopausal women. However, there was a lack of evidence of the effect of etidronate on hip and wrist fractures. For a 65-year-old woman, with 5 years' therapy, the incremental cost per quality-adjusted life-year (QALY) gained for nasal calcitonin was 46,500 Canadian dollars ($Can) compared with no therapy and $Can32,600 compared with etidronate (1998 values). Comparison with alendronate was highly sensitive to the inclusion of one specific trial. CONCLUSIONS: Given the results of the analysis, based on current evidence, nasal calcitonin can be considered at the margins of being cost effective when compared with no therapy. Compared with active therapy, nasal calcitonin can be considered more cost effective than etidronate, but its cost effectiveness versus alendronate is inconclusive.

Massage for low back pain.

BACKGROUND: Low back pain is one of the most common and costly musculoskeletal problems in modern societies. Proponents of massage therapy claim it can minimize pain and disability, and speed return to normal function. OBJECTIVES: To assess the effects of massage therapy for non-specific low back pain. SEARCH STRATEGY: We searched Medline, Embase, Cochrane Controlled Trials Register, Healthstar, CINAHL and Dissertation abstracts from 1966 to 1999 with no language restrictions. References in the included studies and in reviews of the literature were also screened. Contact with content experts and massage associations were also made. SELECTION CRITERIA: This review included randomized, quasi-randomized or controlled clinical trials that investigated the use of any type of massage (using the hands or a mechanical device) as a treatment for nonspecific low back pain. DATA COLLECTION AND ANALYSIS: One reviewer applied the selection criteria and extracted the data. Two reviewers (one blinded to authors, institutions and journals) independently assessed the quality of each trial. A qualitative analysis (best-evidence synthesis) was performed due to clinical heterogeneity among the included trials and insufficient data reported. MAIN RESULTS: Four randomized controlled trials met the inclusion criteria. Two trials were of high and two of low methodological quality. None evaluated massage as the main intervention. Rather, it was the control intervention in studies evaluating manipulation, electrical stimulation, and a lumbar corset. There is limited evidence showing that massage is less effective than manipulation immediately after the first session and moderate evidence showing it is less effective than TENS during the course of sessions in relieving pain and improving activity. At the completion of treatment and at 3 weeks after discharge there is no difference among massage and manipulation, electrical stimulation or corsets, but this evidence is limited. REVIEWER'S CONCLUSIONS: Based on the studies reviewed, there is insufficient evidence to recommend massage as a stand-alone treatment for non-specific low back pain. There is a need for high quality controlled trials to further evaluate the effects of massage for this condition.

Fluoride for treating postmenopausal osteoporosis.

OBJECTIVES: To assess the efficacy of fluoride therapy on bone loss, vertebral and non-vertebral fractures and side effects in postmenopausal women. SEARCH STRATEGY: We searched Medline, Current Contents and the Cochrane Controlled Trial Registry up to December 1998. SELECTION CRITERIA: Two independent reviewers selected RCTs which met predetermined inclusion criteria. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data using predetermined forms and assessed the methodological quality of the trials using a validated scale. For dichotomous outcomes, relative risks (RR) were calculated and for continuous outcomes, weighted mean differences (WMD) of percentage change from baseline were calculated. Where heterogeneity existed (determined by a chi-square test) a random effects model was used. MAIN RESULTS: Eleven studies (1429 subjects) met the inclusion criteria. The increase in lumbar spine bone mineral density (BMD) was found to be higher in the treatment group than in the control group with a WMD 8.1% (95%CI: 7.15,9.09) after two years of treatment and 16.1%(95%CI: 14.65,17.5) after four years. The RR for new vertebral fractures was not significant at two years [0.87 (95%CI: 0.51,1.46)] or at four years [0.9(95%CI: 0.71,1.14)]. The RR for new non-vertebral fractures was not significant at two years 1.2(95%CI: 0.68,2.1) but was increased at four years in the treated group 1.85(95%CI: 1.36,2.5), especially if used at high doses and in a non slow release form. The RR for gastrointestinal side effects was not significant at two years 2.18(95%CI: 0.86,1.21) but was increased at four years in the treated group 2.18(95%CI: 1.69,4.57) especially if fluoride was used at high doses and in a non slow release form. The number of withdrawals and dropouts was not different between treated and control groups at two and four years. REVIEWER'S CONCLUSIONS: Although fluoride has an ability to increase BMD at lumbar spine, it does not result in a reduction of vertebral fractures. In increasing the dose of fluoride, one increases the risk of non-vertebral fracture and gastrointestinal side effects without any effect on the vertebral fracture rate.

Prevention of chronic NSAID induced upper gastrointestinal toxicity.

BACKGROUND: Non-steroidal anti-inflammatory drugs (NSAIDs) are important agents in the management of arthritic and inflammatory conditions, and are among the most frequently prescribed medications in North America and Europe. However, there is overwhelming evidence linking these agents to a variety of gastrointestinal (GI) toxicities. OBJECTIVES: To review the effectiveness of common interventions for the prevention of NSAID induced upper GI toxicity. SEARCH STRATEGY: A literature search was conducted, according to the Cochrane methodology for identification of randomized controlled trials in electronic databases, including MEDLINE from 1966 to January 2000, Current Contents for 6 months prior to January 2000, Embase to Febuary 1999, and a search of the Cochrane Controlled Trials Register from 1973 to 1999. Recent conference proceedings were reviewed and content experts and companies were contacted. SELECTION CRITERIA: Randomized controlled clinical trials (RCTs) of prostaglandin analogues (PA), H2-receptor antagonists (H2RA) or proton pump inhibitors (PPI) for the prevention of chronic NSAID induced upper GI toxicity were included. DATA COLLECTION AND ANALYSIS: Two independent reviewers extracted data regarding population characteristics, study design, methodological quality and number of patients with endoscopic ulcers, ulcer complications, symptoms, overall drop-outs, drop outs due to symptoms. Dichotomous data was pooled using Revman V3.1. Heterogeneity was evaluated using a chi square test. MAIN RESULTS: Thirty-three RCTs met the inclusion criteria. All doses of misoprostol significantly reduced the risk of endoscopic ulcers. Misoprostol 800 ug/day was superior to 400 ug/day for the prevention of endoscopic gastric ulcers (RR=0.18, and RR=0. 38 respectively, p=0.0055). A dose response relationship was not seen with duodenal ulcers. Misoprostol caused diarrhea at all doses, although significantly more at 800ug/day than 400ug/day (p=0.0012). Misoprostol was the only prophylactic agent documented to reduce ulcer complications. Standard doses of H2RAs were effective at reducing the risk of endoscopic duodenal (RR=0.24; 95% CI: 0.10-0. 57) but not gastric ulcers(RR=0.73; 95% CI:0.50-1.09). Both double dose H2RAs and PPIs were effective at reducing the risk of endoscopic duodenal and gastric ulcers (RR=0.44; 95% CI:0.26-0.74 and RR=0.37;95% CI;0.27-0.51 respectively for gastric ulcer), and were better tolerated than misoprostol. REVIEWER'S CONCLUSIONS: Misoprostol, PPIs, and double dose H2RAs are effective at preventing chronic NSAID related endoscopic gastric and duodenal ulcers. Lower doses of misoprostol are less effective and are still associated with diarrhea. Only Misoprostol 800ug/day has been directly shown to reduce the risk of ulcer complications.