Hydration and Fluid Replacement Knowledge, Attitudes, Barriers, and Behaviors of NCAA Division 1 American Football Players.

Judge, LW, Kumley, RF, Bellar, DM, Pike, KL, Pierson, EE, Weidner, T, Pearson, D, and Friesen, CA. Hydration and fluid replacement knowledge, attitudes, barriers, and behaviors of NCAA Division 1 American football players. J Strength Cond Res 30(11): 2972-2978, 2016-Hydration is an important part of athletic performance, and understanding athletes' hydration knowledge, attitudes, barriers, and behaviors is critical for sport practitioners. The aim of this study was to assess National Collegiate Athletic Association (NCAA) Division 1 (D1) American football players, with regard to hydration and fluid intake before, during, and after exercise, and to apply this assessment to their overall hydration practice. The sample consisted of 100 student-athletes from 2 different NCAA D1 universities, who participated in voluntary summer football conditioning. Participants completed a survey to identify the fluid and hydration knowledge, attitudes and behaviors, demographic data, primary football position, previous nutrition education, and barriers to adequate fluid consumption. The average Hydration Knowledge Score (HKS) for the participants in the present study was 11.8 ± 1.9 (69.4% correct), with scores ranging from 42 to 100% correct. Four key misunderstandings regarding hydration, specifically related to intervals of hydration habits among the study subjects, were revealed. Only 24% of the players reported drinking enough fluids before, during, immediately after, and 2 hours after practice. Generalized linear model analysis predicted the outcome variable HKS (χ = 28.001, p = 0.045), with nutrition education (Wald χ = 8.250, p = 0.041) and position on the football team (χ = 9.361, p = 0.025) being significant predictors. "Backs" (e.g., quarterbacks, running backs, and defensive backs) demonstrated significantly higher hydration knowledge than "Linemen" (p = 0.014). Findings indicated that if changes are not made to increase hydration awareness levels among football teams, serious health consequences, including potential fatalities, could occur on the field, especially among heavier linemen.

Analysis of a librarian-mediated literature search service.

Librarian-mediated literature searching is a key service provided at medical libraries. This analysis outlines ten years of data on 19,248 literature searches and describes information on the volume and frequency of search requests, time spent per search, databases used, and professional designations of the patron requestors. Combined with information on best practices for expert searching and evaluations of similar services, these findings were used to form recommendations on the improvement and standardization of a literature search service at a large health library system.

The efficacy and safety of plasma exchange in patients with sepsis and septic shock: a systematic review and meta-analysis.

INTRODUCTION: Sepsis and septic shock are leading causes of intensive care unit (ICU) mortality. They are characterized by excessive inflammation, upregulation of procoagulant proteins and depletion of natural anticoagulants. Plasma exchange has the potential to improve survival in sepsis by removing inflammatory cytokines and restoring deficient plasma proteins. The objective of this study is to evaluate the efficacy and safety of plasma exchange in patients with sepsis. METHODS: We searched MEDLINE, EMBASE, CENTRAL, Scopus, reference lists of relevant articles, and grey literature for relevant citations. We included randomized controlled trials comparing plasma exchange or plasma filtration with usual care in critically ill patients with sepsis or septic shock. Two reviewers independently identified trials, extracted trial-level data and performed risk of bias assessments using the Cochrane Risk of Bias tool. The primary outcome was all-cause mortality reported at longest follow-up. Meta-analysis was performed using a random-effects model. RESULTS: Of 1,957 records identified, we included four unique trials enrolling a total of 194 patients (one enrolling adults only, two enrolling children only, one enrolling adults and children). The mean age of adult patients ranged from 38 to 53 years (n = 128) and the mean age of children ranged from 0.9 to 18 years (n = 66). All trials were at unclear to high risk of bias. The use of plasma exchange was not associated with a significant reduction in all-cause mortality (risk ratio (RR) 0.83, 95% confidence interval (CI) 0.45 to 1.52, I(2) 60%). In adults, plasma exchange was associated with reduced mortality (RR 0.63, 95% CI 0.42 to 0.96; I(2) 0%), but was not in children (RR 0.96, 95% CI 0.28 to 3.38; I(2) 60%). None of the trials reported ICU or hospital lengths of stay. Only one trial reported adverse events associated with plasma exchange including six episodes of hypotension and one allergic reaction to fresh frozen plasma. CONCLUSIONS: Insufficient evidence exists to recommend plasma exchange as an adjunctive therapy for patients with sepsis or septic shock. Rigorous randomized controlled trials evaluating clinically relevant patient-centered outcomes are required to evaluate the impact of plasma exchange in this condition.

The impact of omega-3 polyunsaturated fatty acid supplementation on the incidence of cardiovascular events and complications in peripheral arterial disease: a systematic review and meta-analysis.

BACKGROUND: Individuals with peripheral arterial disease are at higher risk for cardiovascular events than the general population. While supplementation with omega-3 polyunsaturated fatty acids (PUFA) has been shown to improve vascular function, it remains unclear if supplementation decreases serious clinical outcomes. We conducted a systematic review and meta-analysis to determine whether omega-3 PUFA supplementation reduces the incidence of cardiovascular events and complications in adults with peripheral arterial disease. METHODS: We searched five electronic databases (MEDLINE, EMBASE, CENTRAL, Scopus and the International Clinical Trials Registry Platform) from inception to 6 December 2013 to identify randomized trials of omega-3 PUFA supplementation (from fish or plant oils) that lasted ≥12 weeks in adults with peripheral arterial disease. No language filters were applied. Data on trial design, population characteristics, and health outcomes were extracted. The primary outcome was major adverse cardiac events; secondary outcomes included myocardial infarction, cardiovascular death, stroke, angina, amputation, revascularization procedures, maximum and pain-free walking distance, adverse effects of the intervention, and quality of life. Trial quality was assessed using the Cochrane Risk of Bias tool. RESULTS: Of 741 citations reviewed, we included five trials enrolling 396 individuals. All included trials were of unclear or high risk of bias. There was no evidence of a protective association of omega-3 PUFA supplementation against major adverse cardiac events (pooled risk ratio 0.73, 95% CI 0.22 to 2.41, I2 75%, 2 trials, 288 individuals) or other serious clinical outcomes. Adverse events and compliance were poorly reported. CONCLUSIONS: Our results showed that insufficient evidence exists to suggest a beneficial effect of omega-3 PUFA supplementation in adults with peripheral arterial disease with regard to cardiovascular events and other serious clinical outcomes.

Pain management with acupuncture in osteoarthritis: a systematic review and meta-analysis.

BACKGROUND: The utility of acupuncture in managing osteoarthritis symptoms is uncertain. Trial results are conflicting and previous systematic reviews may have overestimated the benefits of acupuncture. METHODS: Two reviewers independently identified randomized controlled trials (up to May 2014) from multiple electronic sources (including PubMed/Medline, EMBASE, and CENTRAL) and reference lists of relevant articles, extracted data and assessed risk of bias (Cochrane's Risk of Bias tool). Pooled data are expressed as mean differences (MD), with 95% confidence intervals (CI) (random-effects model). RESULTS: We included 12 trials (1763 participants) comparing acupuncture to sham acupuncture, no treatment or usual care. We adjudicated most trials to be unclear (64%) or high (9%) risk of bias. Acupuncture use was associated with significant reductions in pain intensity (MD -0.29, 95% CI -0.55 to -0.02, I2 0%, 10 trials, 1699 participants), functional mobility (standardized MD -0.34, 95% CI -0.55 to -0.14, I2 70%, 9 trials, 1543 participants), health-related quality of life (standardized MD -0.36, 95% CI -0.58 to -0.14, I2 50%, 3 trials, 958 participants). Subgroup analysis of pain intensity by intervention duration suggested greater pain intensity reduction with intervention periods greater than 4 weeks (MD -0.38, 95% CI -0.69 to -0.06, I2 0%, 6 trials, 1239 participants). CONCLUSIONS: The use of acupuncture is associated with significant reductions in pain intensity, improvement in functional mobility and quality of life. While the differences are not as great as shown by other reviews, current evidence supports the use of acupuncture as an alternative for traditional analgesics in patients with osteoarthritis. SYSTEMATIC REVIEW REGISTRATION: CRD42013005405.

Risk factors for methamphetamine use in youth: a systematic review.

BACKGROUND: Methamphetamine (MA) is a potent stimulant that is readily available. Its effects are similar to cocaine, but the drug has a profile associated with increased acute and chronic toxicities. The objective of this systematic review was to identify and synthesize literature on risk factors that are associated with MA use among youth.More than 40 electronic databases, websites, and key journals/meeting abstracts were searched. We included studies that compared children and adolescents (< or = 18 years) who used MA to those who did not. One reviewer extracted the data and a second checked for completeness and accuracy. For discrete risk factors, odds ratios (OR) were calculated and when appropriate, a pooled OR with 95% confidence intervals (95% CI) was calculated. For continuous risk factors, mean difference and 95% CI were calculated and when appropriate, a weighted mean difference (WMD) and 95% CI was calculated. Results were presented separately by comparison group: low-risk (no previous drug abuse) and high-risk children (reported previous drug abuse or were recruited from a juvenile detention center). RESULTS: Twelve studies were included. Among low-risk youth, factors associated with MA use were: history of heroin/opiate use (OR = 29.3; 95% CI: 9.8-87.8), family history of drug use (OR = 4.7; 95% CI: 2.8-7.9), risky sexual behavior (OR = 2.79; 95% CI: 2.25, 3.46) and some psychiatric disorders. History of alcohol use and smoking were also significantly associated with MA use. Among high-risk youth, factors associated with MA use were: family history of crime (OR = 2.0; 95% CI: 1.2-3.3), family history of drug use (OR = 4.7; 95% CI: 2.8-7.9), family history of alcohol abuse (OR = 3.2; 95% CI: 1.8-5.6), and psychiatric treatment (OR = 6.8; 95% CI: 3.6-12.9). Female sex was also significantly associated with MA use. CONCLUSION: Among low-risk youth, a history of engaging in a variety of risky behaviors was significantly associated with MA use. A history of a psychiatric disorder was a risk factor for MA for both low- and high-risk youth. Family environment was also associated with MA use. Many of the included studies were cross-sectional making it difficult to assess causation. Future research should utilize prospective study designs so that temporal relationships between risk factors and MA use can be established.

The efficacy and safety of drug treatments for chronic insomnia in adults: a meta-analysis of RCTs.

BACKGROUND: Hypnotics have a role in the management of acute insomnia; however, the efficacy and safety of pharmacological interventions in the management of chronic insomnia is unclear. OBJECTIVE: The objective of this paper is to conduct a systematic review of the efficacy and safety of drug treatments for chronic insomnia in adults. DATA SOURCES: Twenty-one electronic databases were searched, up to July 2006. STUDY SELECTION: Randomized double-blind, placebo-controlled trials were eligible. Quality was assessed using the Jadad scale. Data were pooled using the random effects model. DATA SYNTHESIS: One hundred and five studies were included in the review. Sleep onset latency, as measured by polysomnography, was significantly decreased for benzodiazepines (BDZ), (weighted mean difference: -10.0 minutes; 95% CI: -16.6, -3.4), non-benzodiazepines (non-BDZ) (-12.8 minutes; 95% CI: -16.9, -8.8) and antidepressants (ADP) (-7.0 minutes; 95% CI: -10.7, -3.3). Sleep onset latency assessed by sleep diaries was also improved (BDZ: -19.6 minutes; 95% CI: -23.9, -15.3; non-BDZ: -17.0 minutes; 95% CI: -20.0, -14.0; ADP: -12.2 minutes; 95% CI: -22.3, -2.2). Indirect comparisons between drug categories suggest BDZ and non-BDZ have a similar effect. All drug groups had a statistically significant higher risk of harm compared to placebo (BDZ: risk difference [RD]: 0.15; non-BDZ RD: 0.07; and ADP RD: 0.09), although the most commonly reported adverse events were minor. Indirect comparisons suggest that non-BDZ are safer than BDZ. CONCLUSIONS: Benzodiazepines and non-benzodiazepines are effective treatments in the management of chronic insomnia, although they pose a risk of harm. There is also some evidence that antidepressants are effective and that they pose a risk of harm.

Sports Nutrition Knowledge, Perceptions, Resources, and Advice Given by Certified CrossFit Trainers.

BACKGROUND: CrossFit is a large, growing force in the fitness community. Currently, Level 1 and 2 CrossFit certification classes do not include nutrition education. The purpose of this study was to identify sports nutrition knowledge, perceptions, resources, and advice given by Certified CrossFit Trainers. METHODS: An online questionnaire that measured these four constructs was placed on a private Facebook community, open only to certified CrossFit trainers, for 10 days. RESULTS: Complete surveys were obtained from 289 CrossFit trainers. The mean Sport Nutrition Knowledge (SNK) score was 11.1 ± 2.1, equivalent to 65.3% ± 12.4% correct. The trainers perceived nutrition to be extremely important to athletic performance (9.4 ± 0.9 on a 10 point scale). Overall, the trainers graded their SNK higher than that of their CrossFit peers. The internet and CrossFit peers were the most frequently reported sources for nutrition information; Registered Dietitians were the least reported source. The Paleo and Zone diets were the most common dietary regimens recommended by CrossFit trainers. Results indicated a positive correlation between a CrossFit trainer's self-reported hours of nutrition education and their SNK score (r = 0.17; p < 0.01). CONCLUSION: Nutrition education modules for Level 1 and 2 CrossFit trainers, developed with input from Board Certified Specialists in Sports Dietetics, are recommended.

A systematic review of intentional delivery in women with preterm prelabor rupture of membranes.

OBJECTIVE: To evaluate the effect of intentional delivery versus expectant management in women with preterm prelabor rupture of membranes (PPROM). METHODS: We searched electronic databases and trials registries, contacted experts, and checked reference lists of relevant studies. Studies were included if they were randomized controlled trials comparing intentional delivery versus expectant management after PPROM, the gestational age of participants was between 30 and 36 weeks, and the study reported one of several pre-determined outcomes. RESULTS: Four studies were included in the meta-analysis. No difference was found between intentional delivery and expectant management in neonatal intensive care unit (NICU) length of stay (LOS) (weighted mean difference (WMD) -0.81 day, 95% confidence interval (CI) -1.66, 0.04), respiratory distress syndrome (risk difference (RD) -0.01, 95% CI -0.07, 0.06), and confirmed neonatal sepsis (RD -0.01, 95% CI -0.05, 0.04). One study found a significantly lower incidence of suspected neonatal sepsis among the intentional delivery group (RD -0.31, 95% CI -0.50, -0.12; number needed to treat (NNT) 3, 95% CI 2, 8). Maternal LOS was significantly shorter for the intentional delivery group (WMD -1.39 day, 95% CI -2.03, -0.75). There was a significant difference in the incidence of clinical chorioamnionitis favoring intentional delivery (RD -0.16, 95% CI -0.23, -0.10; NNT 6, 95% CI 5, 11). There was no significant difference in the incidence of other maternal outcomes, including cesarean section (RD 0.05, 95% CI -0.01, 0.11). CONCLUSIONS: Intentional delivery may be favorable to expectant management for some maternal outcomes (chorioamnionitis and LOS). There is insufficient evidence to suggest that either strategy is beneficial or harmful for the baby. Large multicenter trials with primary neonatal outcomes are required to assess whether intentional delivery is associated with less neonatal morbidity.

Challenges in systematic reviews of complementary and alternative medicine topics.

The use of complementary and alternative medicine (CAM) continues to grow in the United States. The Agency for Healthcare Research and Quality has devoted a substantial proportion of the Evidence-based Practice Center (EPC) program to systematic reviews of CAM. Such syntheses present different challenges from those conducted on western medicine topics, and in many ways are more difficult. We discuss 3 challenges: identifying evidence about CAM, assessing the quality of individual studies, and addressing rare serious adverse events. We use illustrations from EPC evidence reports to show readers approaches to the 3 areas and then present specific recommendations for each issue.

Challenges in systematic reviews of therapeutic devices and procedures.

The authors discuss 3 challenges in conducting and interpreting any systematic review that are particularly relevant for systematic reviews of therapeutic devices or surgical procedures: 1) inclusion or exclusion of grey literature, 2) the role of nonrandomized studies, and 3) issues in applying the results to clinical care that are unique to the surgical and therapeutic device literature. The authors also discuss empirical evidence related to these topics and illustrate how reviewers in the Agency for Healthcare Research and Quality's Evidence-based Practice Center program have dealt with these challenges in developing evidence reports for decision makers and clinicians about therapeutic devices or surgical procedures.

Breastfeeding Support in a Community Pharmacy: Improving Access through the Well Babies at Walgreens Program.

Well Babies at Walgreens is a unique community-based corporate partnership program that offers breastfeeding support by a lactation professional in a private room at the pharmacy. Walgreens is a community pharmacy chain with more than 8000 locations in the United States, Puerto Rico, and the US Virgin Islands. The primary goal of Well Babies is to support breastfeeding women using a model that is expandable to other Walgreens pharmacy sites. The Well Babies program offers drop-in services, with a professional consultation by a lactation consultant and baby weight check, if desired. Well Babies creators are developing a business plan for Walgreens and a toolkit that would help other stores implement the program. An additional goal is to improve continuity of care for breastfeeding by engaging pharmacists as vital members of the health care team. Offering breastfeeding support at a pharmacy improves access and encourages support persons to attend while simultaneously allowing the family to complete other errands. This initiative included education for pharmacists to improve the recommendations they make for breastfeeding mothers and to improve awareness among pharmacists of the benefits associated with breastfeeding and the need to preserve the breastfeeding relationship. The first drop-in location opened in April 2012. Grant funding from the US Centers for Disease Control and Prevention, awarded to the Indiana State Department of Health, made it possible to open a second drop-in location in June 2013. Future plans include developing an employee lactation program and expanding Well Babies at Walgreens at other store locations.

The Impact of a Volunteer Postpartum Doula Program on Breastfeeding Success: A Case Study.

Bloomington Area Birth Services (BABS), centered in Bloomington, Indiana, is a community-based program that provides comprehensive education and support for new breastfeeding mothers, infants, family members, and the community by working together with local hospitals, midwives, obstetricians, pediatric offices, and social service agencies to create a seamless continuity of care for families. To help with continuity of care in the community, BABS established a volunteer doula program (birth and postpartum), allowing BABS to combine the services of a community lactation center with birth and postpartum doulas. This article describes the volunteer doula program and highlights one client's story in an effort to encourage and motivate other communities to focus their limited dollars on the development of a volunteer doula program.

Using Videoconferencing Technology to Provide Breastfeeding Support to Low-Income Women: Connecting Hospital-Based Lactation Consultants with Clients Receiving Care at a Community Health Center.

The Tele-Lactation Pilot Project (TLPP), 1 of 13 community-based breastfeeding projects implemented in Indiana in 2013 using Centers for Disease Control and Prevention grant funds, explored the feasibility of using videoconferencing technology to provide breastfeeding education and support to low-income women by a centrally located International Board Certified Lactation Consultant (IBCLC). The IBCLC was housed at the Breastfeeding Center at the hospital where the women would deliver; the women receiving the education and support were located at an inner-city community health center (CHC) where they received their primary care. The videoconferencing sessions were juxtaposed with the women's regularly scheduled prenatal and postnatal visits at the CHC. After delivery, the lactation consultant visited the mother and infant in person at the hospital to offer additional support. Overall, 35 mothers were served by the TLPP during the 9-month project period. A total of 134 visits (30-45 minutes each) were conducted (3.8 sessions per woman). At the conclusion of the project, interviews with key participants indicated that the tele-lactation videoconferencing sessions were easy to implement, allowed the IBCLC to reach a wider client base, and allowed the women to receive expert support that they might not have otherwise received. Comments indicated that, in addition to providing education and increasing the women's confidence, the tele-lactation sessions appeared to have decreased the mothers' anxiety about the birthing process and the hospital experience. The TLPP demonstrated that incorporating videoconferencing technology into routine care can help foster collaboration among health care providers and provide mothers with continuous, easily accessible breastfeeding education and support.

The Bosom Buddy Project: A Breastfeeding Support Group Sponsored by the Indiana Black Breastfeeding Coalition for Black and Minority Women in Indiana.

In 2012, the Indiana Black Breastfeeding Coalition (IBBC) used grant funds to increase participation in the Bosom Buddy Project, an original breastfeeding support group that pairs breastfeeding mothers with trained mentors. Resources for local organizations that support breastfeeding are extremely limited, making it difficult to expand programs and services. This article describes a variety of strategies used by the IBBC to expand programs and services. These activities provide a template for other community-based organizations that wish to provide culturally sensitive breastfeeding support in their community.

Community-Based Participatory Initiatives to Increase Breastfeeding Rates in Indiana.

In 2012, the Centers for Disease Control and Prevention awarded the Indiana State Department of Health funding for breastfeeding activities. The grant, issued in part in response to the 2011 Surgeon General's Call to Action to Support Breastfeeding, focused on providing funding and technical support to small community-based organizations to address challenges encountered by breastfeeding mothers. Indiana used the funds to develop the Community Breastfeeding Support Initiative (CBSI). The goal was to provide funding and technical support to small community-based organizations to carry out self-selected projects in their communities. The 13 CBSI programs served 1345 individual clients (n = 3664 visits) during the 9-month period. This article provides valuable information about collaboration at the state level and the supporting infrastructure in place to carry out this project. Our findings about the number of clients served, number of visits, community-specific programs and activities, and lessons learned can be used by other organizations as they plan breastfeeding support programs for their community.

Breastfeeding knowledge, breastfeeding confidence, and infant feeding plans: effects on actual feeding practices.

OBJECTIVE: To explore relationships among breastfeeding knowledge, breastfeeding confidence, and infant feeding plans and their effects on feeding practices in first-time breastfeeding mothers. DESIGN: Prospective descriptive design. SETTING: Telephone interviews were conducted prenatally and at 6 weeks, 3 months, and 6 months postpartum. PARTICIPANTS: Seventy-four of 83 first-time mothers with prenatal intentions to breastfeed completed all study requirements. The majority were White (95%), between the ages of 21 and 30 years (73%), with a post-high school education (85%), and household incomes of more than 200% of the federal poverty guideline (88%). MAIN OUTCOME MEASURES: Breastfeeding knowledge, breastfeeding confidence, planned infant feeding method, planned breastfeeding duration, weeks of daily human milk substitute feeding, breastfeeding duration, achievement of breastfeeding goals. RESULTS: Breastfeeding knowledge was strongly correlated with breastfeeding confidence (r = .262; p = .025) and actual lactation duration (r = .455; p = .0001). Compared with women planning to exclusively breastfeed their infants, those planning to combination feed planned shorter breastfeeding duration (p = .022), reported shorter actual duration (p = .004), and were less likely to meet their breastfeeding goal (p = .034). The variables maternal education, breastfeeding knowledge, and weeks of daily human milk substitute feeding were used to develop a prediction equation that correctly categorized 93% of participants who met their breastfeeding goal and 90% of those who did not. CONCLUSIONS: Expectations and the actual breastfeeding experience differed among women planning to combination feed and those planning to exclusively breastfeed. Whether a cause or consequence, daily human milk substitute feeding was associated with negative breastfeeding outcomes.

Probiotic supplementation during pregnancy or infancy for the prevention of asthma and wheeze: systematic review and meta-analysis.

OBJECTIVE: To evaluate the association of probiotic supplementation during pregnancy or infancy with childhood asthma and wheeze. DESIGN: Systematic review and meta-analysis of randomised controlled trials. DATA SOURCES: Medline, Embase, and Central (Cochrane Library) databases from inception to August 2013, plus the World Health Organization's international clinical trials registry platform and relevant conference proceedings for the preceding five years. Included trials and relevant reviews were forward searched in Web of Science. REVIEW METHODS: Two reviewers independently identified randomised controlled trials evaluating probiotics administered to mothers during pregnancy or to infants during the first year of life. The primary outcome was doctor diagnosed asthma; secondary outcomes included wheeze and lower respiratory tract infection. RESULTS: We identified 20 eligible trials including 4866 children. Trials were heterogeneous in the type and duration of probiotic supplementation, and duration of follow-up. Only five trials conducted follow-up beyond participants' age of 6 years (median 24 months), and none were powered to detect asthma as the primary outcome. The overall rate of doctor diagnosed asthma was 10.7%; overall rates of incident wheeze and lower respiratory tract infection were 33.3% and 13.9%, respectively. Among 3257 infants enrolled in nine trials contributing asthma data, the risk ratio of doctor diagnosed asthma in participants randomised to receive probiotics was 0.99 (95% confidence interval 0.81 to 1.21, I(2)=0%). The risk ratio of incident wheeze was 0.97 (0.87 to 1.09, I(2)=0%, 9 trials, 1949 infants). Among 1364 infants enrolled in six trials, the risk ratio of lower respiratory tract infection after probiotic supplementation was 1.26 (0.99 to 1.61, I(2)=0%). We adjudicated most trials to be of high (ten trials) or unclear (nine trials) risk of bias, mainly due to attrition. CONCLUSIONS: We found no evidence to support a protective association between perinatal use of probiotics and doctor diagnosed asthma or childhood wheeze. Randomised controlled trials to date have not yielded sufficient evidence to recommend probiotics for the primary prevention of these disorders. Extended follow-up of existing trials, along with further clinical and basic research, are needed to accurately define the role of probiotics in the prevention of childhood asthma. SYSTEMATIC REVIEW REGISTRATION: PROSPERO (CRD42013004385).

Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and midfoot in children: a meta-analysis.

OBJECTIVES: The objectives were to conduct a systematic review to determine the diagnostic accuracy of the Ottawa Ankle Rules (OAR) to exclude ankle and midfoot fractures in children and the extent to which x-ray use could be reduced without missing significant fractures. METHODS: The authors conducted comprehensive searches of electronic databases and gray literature sources. Independent reviewers applied standard inclusion and exclusion criteria. The criterion standard diagnostic test was an ankle and/or foot x-ray or proxy measure to ensure no missed fractures. Standard 2 x 2 tables were constructed. Sensitivities and specificities were pooled using an approximation of the inverse variance; 95% confidence intervals (95% CIs) were calculated using the exact method. Likelihood ratios (LR +/-) and diagnostic odds ratios were combined under DerSimonian and Laird random effects model. RESULTS: A pooled analysis of 12 studies (N = 3,130) identified 671 fractures (prevalence = 21.4%). Ten studies reported Salter-Harris Type I (SH-I) fractures. The pooled sensitivity was 98.5% (95% CI = 97.3 to 99.2), suggesting that the OAR can be used to rule out a fracture. Four of 10 missed fractures were characterized: 1 SH-I, 1 SH-IV, and 2 "insignificant fractures" (either SH-I or avulsion fractures <3 mm). The pooled estimate for rate of x-ray reduction was 24.8% (95% CI = 23.3% to 26.3%; range = 5% to 44%). CONCLUSIONS: The OAR appear to be a reliable tool to exclude fractures in children greater than 5 years of age presenting with ankle and midfoot injuries. Employing the OAR would significantly decrease x-ray use with a low likelihood of missing a fracture.

Cardiac resynchronization therapy and implantable cardiac defibrillators in left ventricular systolic dysfunction.

OBJECTIVES: To determine the efficacy, effectiveness, and safety of cardiac resynchronization therapy (CRT) and/or implantable cardioverter defibrillators (ICD) in patients with left ventricular systolic dysfunction (LVSD). DATA SOURCES: A systematic and comprehensive literature search was conducted to identify randomized controlled trials (RCTs) evaluating efficacy and observational studies evaluating effectiveness or safety of CRT and/or ICD in patients with LVSD. REVIEW METHODS: Study selection, quality assessment, and data extraction were completed by several investigators in duplicate and independently. Random-effects models were used for analyses. RESULTS: From 11,340 citations, we identified 14 RCTs (4,420 patients) for the CRT efficacy review, 106 studies (9,209 patients) for the CRT effectiveness review, 89 studies (9,677 patients) for the CRT safety review, 12 RCTs (8,516 patients) for the ICD efficacy review, 48 studies (15,097 patients) for the ICD effectiveness review, and 49 studies (12,592 patients) for the ICD safety review-all studies enrolled only patients with LVSD. An additional 12 studies (68,848 patients) were included for an analysis of peri-implant outcomes for all patients with ICD (i.e., not only LVSD patients). All patients in the CRT studies had LVSD (mean LVEF from 21 to 30 percent) and prolonged QRS duration (mean from 155 to 209 msec), and 91 percent had New York Heart Association (NYHA) class III or IV symptoms. In patients with LVSD and heart failure symptoms, CRT improved ejection fraction (weighted mean difference 3.0 percent [95% CI, 0.9 to 5.1]), quality of life (weighted mean reduction in Minnesota Living with Heart Failure Questionnaire 8.0 points [95% CI, 5.6 to 10.4 points]), and function (59 percent of CRT recipients vs. 37 percent of controls improved by at least one NYHA class in the RCTs and between 63 percent and 82 percent of CRT recipients improved by at least one NYHA class in observational studies). The proportion of patients hospitalized for HF was reduced by 37 percent (95% CI, 7 to 57 percent) and all-cause mortality was reduced by 22 percent (95% CI, 9 to 33 percent; NNT=29 over 6 months). Implant success rate was 93 percent, 0.3 percent of patients with LVSD died during implantation. Over a median 11-month followup, 6.6 percent of CRT devices exhibited lead problems and 5 percent malfunctioned. In patients with LVSD, ICD reduced all-cause mortality by 20 percent (95% CI, 10 to 29 percent; NNT=20 over 35 months). ICD implant success rate was 99 percent and peri-implant deaths occurred in 1.2 percent of LVSD patients and 1.3 percent of all implantees. The frequency of post-implantation complications in LVSD patients per 100 patient years included 1.4 (95% CI, 1.2 to 1.6) device malfunctions, 1.5 (95% CI, 1.3 to 1.8) lead problems, 0.6 (95% CI, 0.5 to 0.8) implant site infections, and 19.1 (95% CI, 16.5 to 22.0) inappropriate discharges in RCT participants and 4.7 (95% CI, 4.3 to 5.1) inappropriate discharges in patients enrolled in observational studies. CONCLUSIONS: ICD and CRT reduce all-cause mortality in patients with LVSD meeting RCT entry criteria. The incremental benefit of CRT plus ICD over CRT alone in patients with LVSD remains uncertain. None of the trials reported differences in the efficacy of CRT or ICD across patient subgroups, nor did our meta-regression detect any subgroup effects; however, subgroup analyses and meta-regression using aggregate trial data are post-hoc analyses and were underpowered to detect such effects. Examination of individual patient trial data is urgently needed to define which clinical subgroups are most likely to benefit from these devices.