Updating the Canadian clinical practice guideline for managing pediatric obesity: a protocol.

BACKGROUND: Since the first national guideline for managing obesity in adults and children in Canada was published in 2007, new evidence has emerged and guideline standards have evolved. Our purpose is to describe the protocol used to update the Canadian clinical practice guideline for managing pediatric obesity. METHODS: This guideline will update the pediatric components of the 2007 Canadian clinical practice guideline for the management of obesity. In partnership with Obesity Canada, we began preliminary work in 2019; activities are scheduled for completion in 2022. The guideline will follow standards developed by the National Academy of Medicine and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) working group. Guideline development will be informed by 5 complementary literature reviews: a scoping review that focuses on clinical assessment in pediatric obesity management and 4 systematic reviews to synthesize evidence regarding families' values and preferences as well as the safety and effectiveness of interventions (psychological and behavioural; pharmacotherapeutic; and surgical). We will use standard systematic review methodology, including summarizing and assessing the certainty of evidence and determining the strength of recommendations. Competing interests will be managed proactively according to recommendations from the Guidelines International Network. Diverse stakeholders, including families and clinicians, will be engaged throughout guideline development. INTERPRETATION: The guideline will support Canadian families and clinicians to make informed, value-sensitive and evidence-based clinical decisions related to managing pediatric obesity. The guideline and accompanying resources for end-users will be published in English and French, and we will partner with Obesity Canada to optimize dissemination using integrated and end-of-project knowledge translation.

Prolonged opioid use among opioid-naive individuals after prescription for nonspecific low back pain in the emergency department.

ABSTRACT: Low back pain is a leading cause of disability globally. It is a common reason for presentation to the emergency department where opioids are commonly prescribed. This is a retrospective cohort study of opioid-naive adults with low back pain presenting to 1 of 4 emergency departments in Nova Scotia. We use routinely collected administrative clinical and drug-use data (July 2010-November 2017) to investigate the prevalence of prolonged opioid use and associated individual and prescription characteristics. In total, 23,559 eligible individuals presented with nonspecific low back pain, with 84.4% being opioid-naive. Our study population included 4023 opioid-naive individuals who filled a new opioid prescription within 7 days after their index emergency department visit (24.4%). The prevalence of prolonged opioid use after a new opioid prescription for low back pain (filling an opioid prescription 8-90 days after the emergency department visit and filling a subsequent prescription ±30 days of 6 months) was 4.6% (185 individuals). Older age and female sex were associated with clinically important increased odds of prolonged opioid use. First prescription average >90 morphine milligram equivalents/day (odds ratio 1.6, 95% confidence interval 1.0-2.6) and greater than 7-day supply (1.9, 1.1-3.1) were associated with prolonged opioid use in adjusted models. We found evidence of declining opioid prescriptions over the study period, but that 24.3% of first opioid prescriptions in 2016 would not have aligned with current guideline recommendations. Our study provides evidence to support a cautious approach to prescribing in opioid-naive populations.

Dietary interventions for multiple sclerosis-related outcomes.

BACKGROUND: Multiple sclerosis (MS) is a common demyelinating disease of the central nervous system. Although the exact pathogenesis remains unknown, the leading theory is that it results from immune system dysregulation. Approved disease-modifying therapy appears to modulate the immune system to improve MS-related outcomes. There is substantial interest in the ability of dietary interventions to influence MS-related outcomes. This is an update of the Cochrane Review 'Dietary interventions for multiple sclerosis' (Farinotti 2003; Farinotti 2007; Farinotti 2012). OBJECTIVES: To assess the effects of dietary interventions (including dietary plans with recommendations for specific whole foods, macronutrients, and natural health products) compared to placebo or another intervention on health outcomes (including MS-related outcomes and serious adverse events) in people with MS. SEARCH METHODS: On 30 May 2019, we searched CENTRAL, MEDLINE, Embase, and Web of Science. We also searched ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform (ICTRP), and Networked Digital Library of Theses and Dissertations (NDLTD). We checked reference lists in identified trials and requested information from trial authors to identify any additional published or unpublished data. SELECTION CRITERIA: We included any randomized controlled trial (RCT) or controlled clinical trial (CCT) examining the effect of a dietary intervention versus placebo or another intervention among participants with MS on MS-related outcomes, including relapses, disability progression, and magnetic resonance imaging (MRI) measures. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. Planned primary outcomes were number of participants experiencing relapse and change in disability progression, according to a validated disability scale at the last reported follow-up. Secondary outcomes included MRI activity, safety, and patient-reported outcomes. We entered and analysed data in Review Manager 5. MAIN RESULTS: We found 41 full-text articles examining 30 trials following full-text review. Participants were adults with MS, defined by established criteria, presenting to MS clinics in Europe, North America, and the Middle East. Study design varied considerably, although all trials had at least one methodological issue leading to unknown or high risk of bias. Trials examined: supplementation to increase polyunsaturated fatty acids (PUFAs) (11 trials); a variety of antioxidant supplements (10 trials); dietary programmes (3 trials); and other dietary supplements (e.g. acetyl L-carnitine, biotin, creatine, palmitoylethanolamide, probiotic, riboflavin) (6 trials). In three trials comparing PUFAs with monounsaturated fatty acids (MUFAs), the evidence was very uncertain concerning difference in relapses (risk ratio (RR) 1.02, 95% confidence interval (CI) 0.88 to 1.20; 3 studies, 217 participants; 75% in the PUFA group versus 74% in the MUFA group; very low-certainty evidence). Among four trials comparing PUFAs with MUFAs, there may be little to no difference in global impression of deterioration (RR 0.85, 95% CI 0.71 to 1.03; 4 studies, 542 participants; 40% in the PUFA group versus 47% in the MUFA group; low-certainty evidence). In two trials comparing PUFAs with MUFAs (102 participants), there was very low-certainty evidence for change in disability progression. None of the PUFA versus MUFA trials examined MRI outcomes. In one trial comparing PUFAs with MUFAs (40 participants), there were no serious adverse events; based on low-certainty evidence. In two trials comparing different PUFAs (omega-3 versus omega-6), there may be little to no difference in relapses (RR 1.02, 95% CI 0.62 to 1.66; 2 studies, 129 participants; 30% in the omega-3 versus 29% in the omega-6 group; low-certainty evidence). Among three trials comparing omega-3 with omega-6, there may be little to no difference in change in disability progression, measured as mean change in Expanded Disability Status Scale (EDSS) (mean difference (MD) 0.00, 95% CI -0.30 to 0.30; 3 studies, 166 participants; low-certainty evidence). In one trial comparing omega-3 with omega-6, there was likely no difference in global impression of deterioration (RR 0.99, 95% CI 0.51 to 1.91; 1 study, 86 participants; 29% in omega-3 versus 29% in omega-6 group; moderate-certainty evidence). In one trial comparing omega-3 with omega-6 (86 participants), there was likely no difference in number of new T1- weighted gadolinium-enhancing lesions, based on moderate-certainty evidence. In four trials comparing omega-3 with omega-6, there may be little to no difference in serious adverse events (RR 1.12, 95% CI 0.38 to 3.31; 4 studies, 230 participants; 6% in omega-3 versus 5% in omega-6 group; low-certainty evidence). In four trials examining antioxidant supplementation with placebo, there may be little to no difference in relapses (RR 0.98, 95% CI 0.59 to 1.64; 4 studies, 345 participants; 17% in the antioxidant group versus 17% in the placebo group; low-certainty evidence). In six trials examining antioxidant supplementation with placebo, the evidence was very uncertain concerning change in disability progression, measured as mean change of EDSS (MD -0.19, 95% CI -0.49 to 0.11; 6 studies, 490 participants; very low-certainty evidence). In two trials examining antioxidant supplementation with placebo, there may be little to no difference in global impression of deterioration (RR 0.99, 95% 0.50 to 1.93; 2 studies, 190 participants; 15% in the antioxidant group versus 15% in the placebo group; low-certainty evidence). In two trials examining antioxidant supplementation with placebo, the evidence was very uncertain concerning difference in gadolinium-enhancing lesions (RR 0.67, 95% CI 0.09 to 4.88; 2 studies, 131 participants; 11% in the antioxidant group versus 16% in the placebo group; very low-certainty evidence). In three trials examining antioxidant supplementation versus placebo, there may be little to no difference in serious adverse events (RR. 0.72, 95% CI 0.17 to 3.08; 3 studies, 222 participants; 3% in the antioxidant group versus 4% in the placebo group; low-certainty evidence). AUTHORS' CONCLUSIONS: There are a variety of controlled trials addressing the effects of dietary interventions for MS with substantial variation in active treatment, comparator, and outcomes of interest. PUFA administration may not differ when compared to alternatives with regards to relapse rate, disability worsening, or overall clinical status in people with MS, but evidence is uncertain. Similarly, at present, there is insufficient evidence to determine whether supplementation with antioxidants or other dietary interventions have any impact on MS-related outcomes.

Prevalence of Glaucoma in Patients with Obstructive Sleep Apnea.

To determine the prevalence of glaucoma in obstructive sleep apnea (OSA) patients and compare it with that of patients without OSA. Patients investigated for OSA using polysomnography at the sleep center of King Abdulaziz University Hospital were invited to participate in this cross-sectional case series study. American Academy of Sleep Medicine guidelines were used to diagnose OSA. Recruitment of patients with and without OSA was conducted from December 2013 to September 2015. Exclusion criteria included topical and systemic steroid use and presence of other ocular diseases. Two criteria, cup/disc ratio and visual field defects, were necessary for a glaucoma diagnosis. Among 84 adults enrolled, 44 (52%) had a confirmed diagnosis of OSA. Glaucoma prevalence was higher among individuals with OSA (16%) than among non-OSA individuals (8%), a difference that was not statistically significant. A consistent trend, which was not statistically significant after adjusting for cofounders, toward more glaucomatous changes was observed in OSA subjects. Although a trend toward higher glaucoma prevalence was observed in OSA patients, the difference was not statistically significant. As many variables contribute to the development of the two conditions, larger cohorts are needed to evaluate associations between glaucoma and OSA.

Imaging Improves Efficacy of Vertebroplasty - A Systematic Review and Meta-Analysis.

BACKGROUND: Clinical trials with percutaneous vertebral augmentation (PVA) for intractable pain from vertebral compression fractures (VCF) have shown variable results. Variation in the outcomes may be related to poor patient selection on imaging. OBJECTIVE: To assess if PVA augmentation for osteoporotic VCF results in better improvement in pain when patients were selected based on clinical examination plus imaging vs clinical examination only. RESULTS: A systematic review and meta-analysis were performed. PubMed, Embase and Cochrane Library databases were searched from 2000 to May 2018. Two reviewers independently screened and extracted data to identify randomised control trials (RCTs) on PVA for osteoporotic VCF and assessed the risk of bias. Standard systematic review and meta-analysis methods were advocated by the Cochrane Collaboration and PRISMA Statement. A total of 12 RCTs with 1110 participants met the inclusion criteria. Eight of the 10 studies (938 participants) that used imaging to confirm oedema in the target vertebral bodies showed PVA (compared to nonsurgical treatment) was effective in reducing pain (immediate term: mean difference (MD) of -1.89; 95% confidence interval -1.93 to -1.85, p < 0.001; short term: MD of -1.68; 95% CI -1.82 to -1.54, p < 0.001; intermediate term: MD of -2.04; 95% CI -2.15 to -1.94, p < 0.001 and long term: MD of -1.88; 95% CI -1.95 to -1.80, p < 0.001). CONCLUSIONS: RCTs using imaging to confirm marrow oedema in the index vertebra showed an improved size effect compared to RCTs using no imaging. This benefit was observed in the immediate, short, intermediate and long term.

Améliorer l'efficacité de la vertébroplastie au moyen de l'imagerie médicale : une revue systématique et une méta-analyse.Contexte: Des essais cliniques au cours desquels on a fait appel aux techniques percutanées de la vertébroplastie (vertebral augmentation) pour soulager des douleurs réfractaires produites par des fractures vertébrales par compression (FVC) ont donné à voir des résultats variables. Cette variabilité pourrait être liée à une mauvaise sélection des participants au moyen d'examens d'IRM. Objectif: Évaluer dans quelle mesure la vertébroplastie entraîne un soulagement accru de la douleur dans le cas de patients aux prises avec des FVC d'origine ostéoporotique. On a ainsi voulu comparer des patients choisis en fonction d'un examen clinique et d'un examen d'IRM avec d'autres patients choisis en fonction d'un seul examen clinique. Résultats: Nous avons mené une revue systématique ainsi qu'une méta-analyse. Pour ce faire, nous avons effectué des recherches dans les bases de données suivantes : PubMed, Embase et Cochrane, et ce, de l'année 2000 au mois de mai 2018. Deux examinateurs indépendants ont ensuite extrait et passé au crible des données afin d'identifier les essais cliniques randomisés (ECR) portant sur la vertébroplastie dans le cas de FVC d'origine ostéoporotique et d'évaluer les risques de biais. À noter que notre revue systématique et notre méta-analyse ont été effectuées en tenant compte des méthodes recommandées par Cochrane et PRISMA. Au total, douze ECR incluant 1110 participants ont satisfait à nos critères de sélection. Sur 10 ECR (938 participants) dans lesquels on a recouru à un examen d'IRM pour confirmer la présence d'un œdème dans les corps vertébraux ciblés, 8 d'entre eux ont révélé que le recours à la vertébroplastie était plus efficace qu'un traitement non-chirurgical dans le soulagement de la douleur (sur le champ : écart moyen de -1,89 ; IC 95 % -1,93 à -1,85 ; p < 0,001 ; à court terme : écart moyen de -1,68 ; IC 95 % -1,82 à -1,54 ; p < 0,001 ; à moyen terme : écart moyen de -2,04 ; IC 95 % -2,15 à -1,94 ; p < 0,001 ; et à long terme : écart moyen de -1,88 ; IC 95% -1,95 à -1,80 ; p < 0,001). Conclusions: En somme, les ECR utilisant des examens d'IRM pour confirmer la présence d'œdèmes de la moelle épinière dans une vertèbre de référence (index vertebra) ont révélé une taille d'effet améliorée si on les compare à des ECR n'utilisant pas ces examens. Cet avantage a été observé sur le champ mais aussi à court, moyen et long terme.

Restless legs syndrome and sleep quality among adult sickle cell disease patients.

OBJECTIVE: The purpose of this study is to determine and compare the prevalence of restless legs syndrome (RLS) between adult patients with sickle cell disease (SCD) and non-SCD anemia. METHODS: This cross-sectional study was conducted from December 2013 to July 2014. Patients with SCD and non-SCD anemia were recruited from a hematology clinic at a large university hospital. Patients with secondary RLS were excluded. Data were collected on demographic features, clinical evaluations, laboratory tests, sleep quality using the Pittsburgh Sleep Quality Index, RLS symptoms using the International Restless Legs Syndrome Study Group Criteria, severity of RLS using the International Restless Leg Syndrome Rating Scale, and daytime sleepiness using the Epworth Sleepiness Scale. RESULTS: The study sample consisted of 44 patients with SCD and 45 with non-SCD anemia. The two groups were comparable in age, gender, body mass index, smoking habit, and comorbidities. Poor sleep quality was found in 63% of the SCD group compared to 53% of the non-SCD group. The prevalence of RLS among SCD group and non-SCD group was 13.6% (6/44) and 8.8% (4/45), respectively. These differences, however, were not statistically significant, p > 0.05. Excessive daytime sleepiness was also similar in both groups, with the rate being 20.5 and 17.8% in the SCD and non-SCD groups, respectively. CONCLUSION: Our study revealed that poor sleep quality and RLS were both common among adult patients with SCD; however, they did not differ significantly from patients with non-SCD anemia.

Sleepiness in Adolescents.

Sleepiness and sleep deprivation among adolescents are increasingly being recognized as a public health concern. Many of the determinants of this growing problem lie beyond the biomedical scope of explanation. In this article, the authors begin with a review of the prevalence and consequences of sleepiness in adolescents and then present the approach to a sleepy adolescent and the underlying cause. The topic is discussed from clinical as well as public health perspectives.

Sleep quantity, quality, and insomnia symptoms of medical students during clinical years. Relationship with stress and academic performance.

OBJECTIVES: To determine sleep habits and sleep quality in medical students during their clinical years using validated measures; and to investigate associations with academic performance and psychological stress. METHODS: In this cross-sectional study, medical students (n=320) were randomly selected from a list of all enrolled clinical-year students in a Saudi medical school from 2011-2012. Students filled a questionnaire including demographic and lifestyle factors, Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, and Perceived Stress Scale. RESULTS: Students acquired on average, 5.8 hours of sleep each night, with an average bedtime at 01:53. Approximately 8% reported acquiring sleep during the day, and not during nighttime. Poor sleep quality was present in 30%, excessive daytime sleepiness (EDS) in 40%, and insomnia symptoms in 33% of students. Multivariable regression models revealed significant associations between stress, poor sleep quality, and EDS. Poorer academic performance and stress were associated with symptoms of insomnia. CONCLUSION: Sleep deprivation, poor sleep quality, and EDS are common among clinical years medical students. High levels of stress and the pressure of maintaining grade point averages may be influencing their quality of sleep.

Sleep habits in adolescents of Saudi Arabia; distinct patterns and extreme sleep schedules.

BACKGROUND AND STUDY OBJECTIVES: There is a need for comprehensive studies on adolescents' sleep habits in the Middle Eastern region. The aim of this study was to investigate the sleep-wake patterns, prevalence of excessive daytime sleepiness (EDS), and disturbed sleep among adolescents in Saudi Arabia and to identify the associated factors. METHODS: The study was a cross-sectional survey done on a random sample of 1035 high school students, ages 14-23 years, in Jeddah, Saudi Arabia. The response rate was 91%. Students filled a self-reported questionnaire that included sleep-wake questions, Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, Perceived Stress Scale, academic performance, and personal data. RESULTS: Students slept an average of 7.0 hours on school nights, with an average delay of 2.8 and 6.0 hours in weekend sleep and rise times, respectively. Around 1 in 10 students stayed up all night and slept after returning from school (exhibiting a reversed sleep cycle) on weeknights. This pattern was more prevalent among boys and students with lower grade point averages. The prevalence of sleep disturbance was 65%, and EDS was found in 37% of the students. Predictors of EDS were school type, stress, napping and caffeine use, while gender was a predictor of disturbed sleep. CONCLUSIONS: Adolescents in Saudi Arabia showed a high percentage of poor sleep quality. Compared with adolescents from other countries, they had a larger delay in weekend sleep and rise times. An alarming reversed sleep cycle on weekdays is present and highlights the need for further assessment.