Race Adjustment of Pulmonary Function Tests in the Diagnosis and Management of COPD: A Scoping Review.

Aim: Increasing evidence suggests that the inclusion of self-identified race in clinical decision algorithms may perpetuate longstanding inequities. Until recently, most pulmonary function tests utilized separate reference equations that are race/ethnicity based. Purpose: We assess the magnitude and scope of the available literature on the negative impact of race-based pulmonary function prediction equations on relevant outcomes in African Americans with COPD. Methods: We performed a scoping review utilizing an English language search on PubMed/Medline, Embase, Scopus, and Web of Science in September 2022 and updated it in December 2023. We searched for publications regarding the effect of race-specific vs race-neutral, race-free, or race-reversed lung function testing algorithms on the diagnosis of COPD and COPD-related physiologic and functional measures. Joanna Briggs Institute (JBI) guidelines were utilized for this scoping review. Eligibility criteria: The search was restricted to adults with COPD. We excluded publications on other lung disorders, non-English language publications, or studies that did not include African Americans. The search identified publications. Ultimately, six peer-reviewed publications and four conference abstracts were selected for this review. Results: Removal of race from lung function prediction equations often had opposite effects in African Americans and Whites, specifically regarding the severity of lung function impairment. Symptoms and objective findings were better aligned when race-specific reference values were not used. Race-neutral prediction algorithms uniformly resulted in reclassifying severity in the African Americans studied. Conclusion: The limited literature does not support the use of race-based lung function prediction equations. However, this assertion does not provide guidance for every specific clinical situation. For African Americans with COPD, the use of race-based prediction equations appears to fall short in enhancing diagnostic accuracy, classifying severity of impairment, or predicting subsequent clinical events. We do not have information comparing race-neutral vs race-based algorithms on prediction of progression of COPD. We conclude that the elimination of race-based reference values potentially reduces underestimation of disease severity in African Americans with COPD.

Evidence Base Update on Behavioral Treatments for Overweight and Obesity in Children and Adolescents.

OBJECTIVE: This review provides an update to a previous Evidence Base Update addressing behavioral treatments for overweight and obesity in children and adolescents. METHOD: Articles were identified through a systematic search of the biomedical literature in PubMed/MEDLINE (1946-), Elsevier EMBASE (1947-), SCOPUS (1823-), Clarivate Web of Science Core Collection (WOS, 1900-), PsycINFO (1800-), The Cochrane Library and Clinicaltrials.gov published between June 2014 and August 2022. RESULTS: Family-based treatment (FBT) remains a well-established treatment for overweight and obesity in children and is now well-established in adolescents and toddlers. Parent-only behavioral treatment remains well-established in children and is now well-established among adolescents and children. Possibly effective treatments continue to include FBT-parent only for adolescents, and behavioral weight loss (BWL) with a family component for adolescents, children, and toddlers. Several variations of FBT and BWL can now be considered possibly effective including FBT+motivational interviewing, FBT+social facilitation maintenance, group-based FBT, low-dose FBT, BWL+stress management, and camp-based BWL. Cognitive behavioral treatment (CBT) for adolescents also met criteria for possibly effective treatments. Current research has also established that behavioral treatments can be effectively delivered in alternative settings (e.g. primary care) and through alternative mediums (e.g. telehealth). CONCLUSIONS: Research continues to support the use of multicomponent lifestyle interventions in accordance with recent recommendations from the American Academy of Pediatrics, the American Psychological Association, and the United State Preventative Services Task Force. However, more work is needed to ensure appropriate access for children with comorbid medical and psychiatric disorders and children from socially, politically, and economically marginalized groups.

Time to Mohs Reconstruction: A Systematic Review Comparing Complication Rates between Immediate and Delayed Repair.

Several known factors affect outcomes of Mohs facial defect reconstruction; however, the effect of repair timing on outcomes is ill-defined. The aim of this study was to determine postoperative complication rates between immediate and delayed repair of Mohs facial defects. Preferred Reporting Items of Systematic Reviews and Meta-Analyses guidelines were used. Articles were selected using PICO format-population: Mohs facial defect patients, intervention: defect repair, comparator: immediate (<24 hours), or delayed (>24 hours) repair, outcome: complication rate. PubMed/Medline (1946-2020), EMBASE (1947-2020), Scopus (1823-2020), Web of Science (1900-2020), Cochrane Library, and Clinicaltrials.gov were searched. Two independent reviewers screened abstracts; those in English with human subjects reporting repair timing and complication rates were included. Search criteria yielded 6,649 abstracts; 233 qualified for review. Data were gathered from six studies; they alone contained comparative data meeting inclusion criteria. While many well-written studies were encountered, reported results varied widely. A statistically sound meta-analysis could not be completed due to large heterogeneity between studies, biasing the analysis towards the largest weighted study. Clinically important differences may exist between immediate and delayed Mohs reconstruction, but small study numbers, large heterogeneity, and lack of standardized outcome measures limit definitive conclusions. More studies are needed to perform appropriate meta-analyses, including studies using standardized methods of reporting Mohs outcome data.

Clinical practice guideline and expert consensus recommendations for rehabilitation among children with cancer: A systematic review.

Increased attention to the rehabilitation needs of children with cancer is vital to enhance health, quality-of-life, and productivity outcomes. Among adults with cancer, rehabilitation recommendations are frequently incorporated into guidelines, but the extent to which recommendations exist for children is unknown. Reports included in this systematic review are guideline or expert consensus reports containing recommendations related to rehabilitation referral, evaluation, and/or intervention for individuals diagnosed with cancer during childhood (younger than 18 years). Eligible reports were published in English from January 2000 to August 2022. Through database searches, 42,982 records were identified; 62 records were identified through citation and website searching. Twenty-eight reports were included in the review: 18 guidelines and 10 expert consensus reports. Rehabilitation recommendations were identified in disease-specific (e.g., acute lymphoblastic leukemia), impairment-specific (e.g., fatigue, neurocognition, pain), adolescent and young adult, and long-term follow-up reports. Example recommendations included physical activity and energy-conservation techniques to address fatigue, referral to physical therapy for chronic pain management, ongoing psychosocial surveillance, and referral to speech-language pathology for those with hearing loss. High-level evidence supported rehabilitation recommendations for long-term follow-up care, fatigue, and psychosocial/mental health screening. Few intervention recommendations were included in guideline and consensus reports. In this developing field, it is critical to include pediatric oncology rehabilitation providers in guideline and consensus development initiatives. This review enhances the availability and clarity of rehabilitation-relevant guidelines that can help prevent and mitigate cancer-related disability among children by supporting access to rehabilitation services.

What is the Rate of Response to Nonoperative Treatment for Hip-Related Pain? A Systematic Review With Meta-analysis.

OBJECTIVE: We aimed to (1) determine the rate of satisfactory response to nonoperative treatment for nonarthritic hip-related pain, and (2) evaluate the specific effect of various elements of physical therapy and nonoperative treatment options aside from physical therapy. DESIGN: Systematic review with meta-analysis. LITERATURE SEARCH: We searched 7 databases and reference lists of eligible studies from their inception to February 2022. STUDY SELECTION CRITERIA: We included randomized controlled trials and prospective cohort studies that compared a nonoperative management protocol to any other treatment for patients with femoroacetabular impingement syndrome, acetabular dysplasia, acetabular labral tear, and/or nonarthritic hip pain not otherwise specified. DATA SYNTHESIS: We used random-effects meta-analyses, as appropriate. Study quality was assessed using an adapted Downs and Black checklist. Certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach. RESULTS: Twenty-six studies (1153 patients) were eligible for qualitative synthesis, and 16 were included in the meta-analysis. Moderate certainty evidence suggests that the overall response rate to nonoperative treatment was 54% (95% confidence interval: 32%, 76%). The overall mean improvement after physical therapy treatment was 11.3 points (7.6-14.9) on 100-point patient-reported hip symptom measures (low to moderate certainty) and 22.2 points (4.6-39.9) on 100-point pain severity measures (low certainty). No definitive specific effect was observed regarding therapy duration or approach (ie, flexibility exercise, movement pattern training, and/or mobilization) (very low to low certainty). Very low to low certainty evidence supported viscosupplementation, corticosteroid injection, and a supportive brace. CONCLUSION: Over half of patients with nonarthritic hip-related pain reported satisfactory response to nonoperative treatment. However, the essential elements of comprehensive nonoperative treatment remain unclear. J Orthop Sports Phys Ther 2023;53(5):1-21. Epub 9 March 2023. doi:10.2519/jospt.2023.11666.

The Use and Effectiveness of the Whole School Approach in School-Based Interventions Addressing Gender-Based Violence in Sub-Saharan Africa: A Systematic Review.

Adolescents and young people in sub-Saharan Africa (SSA) experience high rates of gender-based violence (GBV). The whole school approach (WSA) is an established benchmark of effective school-based interventions to address this issue. We conducted a systematic review of peer-reviewed literature using PubMed/Medline, EMBASE, Scopus, Web of Science, Cochrane Library, Clinicaltrials.gov, and Google Scholar (1) to determine the characteristics, measured outcomes, and effectiveness of school-based GBV interventions and (2) to examine each papers' alignment with WSA and methodological quality. We developed a comprehensive intervention characteristics form for data extraction and analyzed the selected studies' quality using the modified Methodological Quality Rating Scale. To measure alignment with WSA implementation standards, we expanded the application of the WSA by creating the Whole School Approach Rating Scale (WSARS) for assessing school-based GBV interventions. Most interventions (n = 14/16) we reviewed effectively addressed at least one of the three outcomes of interest (i.e., sexual violence, physical violence, and GBV-related knowledge/attitudes). Over half (n = 9/16) of the studies were rated high on the WSARS. However, we observed no significant differences in effectiveness between studies rated high and those rated low on the WSARS. Our results indicate that school-based GBV interventions could be an effective and sustainable strategy for addressing GBV in and around schools.

Carotid Blowout Syndrome in Head and Neck Cancer Patients: Management of Patients At Risk for CBS.

OBJECTIVES: Carotid blowout syndrome (CBS) is an acute, rare life-threatening hemorrhage that occurs in patients with a history of head and neck cancer and radiation therapy. The primary objective of this review was to identify risk factors and assess treatment and survival outcomes following CBS. METHODS: A systematic review of published literature was performed. Information including risk factors, treatment, and outcomes of CBS were collected. RESULTS: A total of 49 articles and 2220 patients were included in the systematic review. Risk factors for developing CBS included a history of radiation therapy, wound complications, and advanced tumor stage. The initial management of CBS included establishing a stable airway, gaining hemostasis, and repletion of blood loss. Endovascular and surgical procedures treat CBS with infrequent rates of rebleeding and periprocedural complications. Short-term survival following treatment of CBS shows high survival rates when considering CBS-related complications and underlying disease, however, long-term survival related to the underlying disease demonstrated high mortality. CONCLUSIONS: Identifying patients at risk for CBS enables practitioners to counsel patients on life-saving interventions and expected outcomes following treatment of CBS. Treatment of CBS is associated with high short-term survival, although long-term survival related to underlying disease is low. LEVEL OF EVIDENCE: N/A Laryngoscope, 133:576-587, 2023.

Empowerment in people with Parkinson's disease: A scoping review and qualitative interview study.

OBJECTIVE: To synthesize empowerment definitions in Parkinson's disease (PD) literature and understand people with PD's perspective on empowerment in the context of an existing empowerment conceptual model. METHODS: This mixed-methods study included a scoping review of PD empowerment literature and interviews with adults with PD. Five databases were searched for articles that defined empowerment concepts. We analyzed 1:1 semi-structured interviews on empowerment with people with PD. All data were analyzed using hybrid thematic analysis. RESULTS: Eight of 242 records were included in this review. Empowerment is defined as an intrapersonal (e.g., personal control over oneself or healthcare) or interpersonal construct (e.g., person-centered care). Thirty-seven participants completed the interview. Participants perceived empowerment as a multifaceted concept that interacts with determinants and moderators from different ecological levels. CONCLUSION: Empowerment is a noteworthy multilevel and relational construct that can interplay with important health-related factors. The developed working conceptual model of empowerment can inform future studies to explore empowerment concepts in more depth and develop PD empowerment-based interventions. PRACTICE IMPLICATIONS: The empowerment definitions, indicators, determinants, and moderators identified in this study can help researchers, clinicians, and policymakers critically conceptualize empowerment and develop interventions to support people with PD.

Person-Centered Goal Setting: A Systematic Review of Intervention Components and Level of Active Engagement in Rehabilitation Goal-Setting Interventions.

OBJECTIVE: This systematic review aims to examine (1) what components are used in current person-centered goal-setting interventions for adults with health conditions in rehabilitation and (2) the extent to which the engagement of people in their rehabilitation goal setting is encouraged. DATA SOURCES: PubMed/MEDLINE, Embase, Cumulative Index of Nursing and Allied Health Literature, Scopus, and Web of Science from inception to November 2020. STUDY SELECTION: Primary inclusion criteria were peer-reviewed articles that evaluated person-centered goal-setting interventions for adults with health conditions in rehabilitation. Two independent reviewers screened 28,294 records, and 22 articles met inclusion criteria. DATA EXTRACTION: Two reviewers independently completed data extraction and quality assessment using the Physiotherapy Evidence Database (PEDRo) scale based on the original authors' descriptions, reports, and protocol publications. Any discrepancies were resolved by consensus or in consultation with another senior reviewer. DATA SYNTHESIS: Using narrative synthesis, we found that current person-centered goal setting has variability in their inclusion of intervention components. A considerable number of components are underimplemented in current practice, with formulation of coping plan and follow-up being most commonly left out. The active engagement of people does appear to be promoted within the components that are included in the interventions. Nine studies were high-quality defined as a total PEDro scale score of 6 or above. CONCLUSIONS: Although current person-centered goal setting encourages the active engagement of people, many of these interventions lack components considered important for supporting goal achievement and optimal outcomes. Future practice may be improved by incorporating a comprehensive set of goal-setting components and encouraging the active engagement of people throughout the entire goal-setting process. Together, these practices may facilitate the achievement of meaningful rehabilitation goals and improve rehabilitation outcomes for adults with health conditions.

Clinical predictive models of invasive Candida infection: A systematic literature review.

Clinical predictive models (CPM) serve to identify and categorize patients into risk categories to assist in treatment and intervention recommendations. Predictive accuracy and practicality of models varies depending on methods used for their development, and should be evaluated. The aim of this study was to summarize currently available CPM for invasive candidiasis, analyze their performance, and assess their suitability for use in clinical decision making. We identified studies that described the construction of a CPM for invasive candidiasis from PubMed/MEDLINE, EMBASE, SCOPUS, Web of Science, Cochrane Library databases, and Clinicaltrials.gov. Data extracted included: author, data source, study design, recruitment period, characteristics of study population, outcome types, predictor types, number of study participants and outcome events, modelling method, and list of predictors used in the final model. Calibration and discrimination in the derivative datasets were used to assess the performance of each model. Ten articles were identified in our search and included for full text review. Five models were developed using data from ICUs, and five models included all hospitalized patients. The findings of this review highlight the limitations of currently available models to predict invasive candidiasis, including lack of generalizability, difficulty in everyday clinical use, and overly optimistic performance. There are significant concerns regarding predictive performance and usability in every day practice of existing CPM to predict invasive candidiasis.

Clinical predictive models may assist in early identification of patients at risk for invasive candidiasis to initiate appropriate treatment. The findings of this systematic review highlight the limitations of currently available models to predict invasive candidiasis.

Microvascular platelet aggregation and thrombosis after subarachnoid hemorrhage: A review and synthesis.

Delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (SAH) has been associated with numerous pathophysiological sequelae, including large artery vasospasm and microvascular thrombosis. The focus of this review is to provide an overview of experimental animal model studies and human autopsy studies that explore the temporal-spatial characterization and mechanism of microvascular platelet aggregation and thrombosis following SAH, as well as to critically assess experimental studies and clinical trials highlighting preventative therapeutic options against this highly morbid pathophysiological process. Upon review of the literature, we discovered that microvascular platelet aggregation and thrombosis occur after experimental SAH across multiple species and SAH induction techniques in a similar time frame to other components of DCI, occurring in the cerebral cortex and hippocampus across both hemispheres. We discuss the relationship of these findings to human autopsy studies. In the final section of this review, we highlight the important therapeutic options for targeting microvascular platelet aggregation and thrombosis, and emphasize why therapeutic targeting of this neurovascular pathology may improve patient care. We encourage ongoing research into the pathophysiology of SAH and DCI, especially in regard to microvascular platelet aggregation and thrombosis and the translation to randomized clinical trials.

The effectiveness of treatment supporter interventions in antiretroviral treatment adherence in sub-Saharan Africa: a systematic review and meta-Analysis.

This systematic review and meta-analysis evaluated the effectiveness of treatment supporter interventions (TSI) in improving ART adherence and viral suppression among adults living with HIV (PLWH) in sub-Saharan Africa. This review included ten randomized controlled trials (RCT) and six cohort studies comparing treatment support interventions to the standard of care (SOC). Primary outcomes include pill count ART adherence and viral load suppression (VLS). Pooled relative risk ratios (PRR) with 95% confidence intervals were generated using random-effects models. Stratified analyses and meta-regressions were conducted to determine the effect of study type, follow-upperiod, and patient treatment supporters on ART adherence. Treatment supporters included partners, friends, family members, trained community health workers, and HIV positive peers. TSIs were associated with a 7.6% higher ART adherence compared to the SOC group (PRR = 1.076, [95% CI = 1.005, 1.151]). VLS was 5% higher in the treatment group compared to the SOC group (PRR = 1.05, [95% CI = 1.061, 1.207]). There was a significant, positive association between TSIs and VLS in community-based delivery settings but not in facility-based settings. TSIs were statistically significant for VLS in cohort study designs (RR = 1.073, [95% CI = 1.028, 1.121]) but not in RCTs. Findings suggest that TSIs critical in facilitating optimal ART adherence and VLS among PLWHs.

Simulation Training for Operative Vaginal Delivery Among Obstetrics and Gynecology Residents: A Systematic Review.

OBJECTIVE: To perform a systematic review of the literature on the effect of simulation training of operative vaginal delivery on learner technique and knowledge, operator comfort, and patient-centered outcomes. DATA SOURCES: MEDLINE, EMBASE, CINAHL, Scopus, Web of Science, ERIC, The Cochrane Library, and ClinicalTrials.gov were searched from inception through April 2017. The search criteria used MeSH terms ("simulation training," "high fidelity simulation training," "teaching," "obstetrical extraction," "obstetrical forceps," "vaginal delivery," "clinical competence," and "internship and residency"). METHODS OF STUDY SELECTION: A total of 30,813 articles were reviewed for inclusion. Studies detailing operative vaginal delivery simulation using forceps or vacuums and reporting health care provider or patient outcomes were eligible. TABULATION, INTEGRATION, AND RESULTS: All studies were independently reviewed by two investigators for inclusion. Only eight articles assessed the effect of simulation on trainee skill and comfort or patient outcomes and were included. Four were pretest-posttest studies, two were cross-sectional studies, one was a case-control study, and one was a cohort study. No randomized trials were identified. Simulation was associated with improved forceps placement accuracy and generated force during extraction, as well as increased operator knowledge and comfort with operative vaginal delivery. Additionally, simulation had no association with forceps failure rates, but there was an association with decreased rates of maternal lacerations and neonatal injury. The quality of the included studies was assessed with the Medical Education Research Study Quality Instrument, with a median score of 9.75 (range 9.0-13.5), indicating low-to-moderate quality. CONCLUSION: The available evidence suggests that improved technique, comfort, knowledge, and patient outcomes are associated with operative vaginal delivery simulation, but additional studies are required to further characterize such benefits for both forceps and vacuum. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42018087343.

Patterns of unmet needs in adolescent and young adult (AYA) cancer survivors: in their own words.

PURPOSE: Categorization of the needs of AYA cancer survivors is primarily based on quantitative analyses of epidemiological and observational research. The present study classified the phenomenological experiences of AYA survivors based on their own language. METHODS: A systematic approach for selecting qualitative studies of unmet needs in AYA cancer survivors was used. Following selection based on quality, survivor statements were entered verbatim and thematic analysis was conducted using NVivo qualitative research software. RESULTS: A total of 1993 AYA cancer survivors (post-treatment) were included in 58 studies (78% individual interviews). Mean age was 27.6 with an average of 8.6 years post-primary treatment. The organizational framework reported in this study was based on a heterogeneous group of cancer types. Thirteen themes including symptoms, function, reproductive health, emotional well-being, health management, health care system, social interaction, romantic relationships, cancer disclosure, normalcy, career development and employment, and school and fiscal concerns were identified. Forty-eight subthemes were also identified covering such areas as fertility, integrative health services, advice for cancer disclosure, family interaction, and insurance challenges. CONCLUSION: Direct analysis of text identified many common unmet needs similarly reported in the quantitative literature. The phenomenological data also provided a breakdown of unmet needs into subthemes or elements of unmet needs. IMPLICATIONS FOR CANCER SURVIVORS: This information can help form the basis for a personalized, valid, and reliable evaluation tool of the range of unmet needs in AYA survivors.

Maternal Marijuana Use and Adverse Neonatal Outcomes: A Systematic Review and Meta-analysis.

OBJECTIVE: To estimate whether marijuana use in pregnancy increases risks for adverse neonatal outcomes and clarify if any increased risk is attributable to marijuana use itself or to confounding factors such as tobacco use. DATA SOURCES: Two authors performed a search of the data through August 2015 utilizing PubMed, Embase, Scopus, Cochrane reviews, ClinicalTrials.gov, and Cumulative Index to Nursing and Allied Health. METHODS OF STUDY SELECTION: We looked at observational studies that compared rates of prespecified adverse neonatal outcomes in women who used marijuana during pregnancy with women who did not. TABULATION, INTEGRATION, AND RESULTS: Two authors independently extracted data from the selected studies. Primary outcomes were low birth weight (less than 2,500 g) and preterm delivery at less than 37 weeks of gestation. Secondary outcomes were birth weight, gestational age at delivery, small for gestational age, level II or greater nursery admission, stillbirth, spontaneous abortion, low Apgar score, placental abruption, and perinatal death. DerSimonian-Laird random-effects models were used. We assessed heterogeneity using the Q test and I statistic. Stratified analyses were performed for the primary outcomes and pooled adjusted estimates were calculated. We included 31 studies that assessed the effects of maternal marijuana use on adverse neonatal outcomes. Based on pooled unadjusted data, marijuana use during pregnancy was associated with an increased risk of low birth weight (15.4% compared with 10.4%, pooled relative risk [RR] 1.43, 95% confidence interval [CI] 1.27-1.62) and preterm delivery (15.3% compared with 9.6%, pooled RR 1.32, 95% CI 1.14-1.54). However, pooled data adjusted for tobacco use and other confounding factors showed no statistically significant increased risk for low birth weight (pooled RR 1.16, 95% CI 0.98-1.37) or preterm delivery (pooled RR 1.08, 95% CI 0.82-1.43). CONCLUSION: Maternal marijuana use during pregnancy is not an independent risk factor for adverse neonatal outcomes after adjusting for confounding factors. Thus, the association between maternal marijuana use and adverse outcomes appears attributable to concomitant tobacco use and other confounding factors.

Prehospital emergency services screening and referral to reduce falls in community-dwelling older adults: a systematic review.

BACKGROUND: Falls represent an increasing source of geriatric morbidity and mortality. Prehospital emergency services may be uniquely suited to screen and refer subsets of high-risk older adults to fall prevention programmes. This systematic review assesses the effectiveness of such screening and referral programmes. METHODS: We searched PubMed, Embase, CINAHL, Web of Science, Scopus, the Cochrane Library and OTseeker for English-language peer-reviewed randomised trials, non-randomised trials and cohort studies evaluating prehospital fall risk screening and referral programmes for community-dwelling adults ≥60 years of age. Risk of bias was assessed using the Cochrane Collaboration's tool. Primary outcomes included the risk and rate of falling. Secondary outcomes included successful follow-up to address fall risks and adverse events. RESULTS: From 6187 unique records, 6 studies were included. Screening varied from using semistructured risk assessments to recording chief complaints. All studies were at high risk of bias. One unblinded trial of a multifactorial fall prevention programme demonstrated a 14.3% (95% CI 6.1% to 22.5%) absolute reduction in annual fall risk and a relative fall incidence of 0.45 (95% CI 0.35 to 0.58). The probability of successful follow-up varied from 9.8% to 81.0%. No studies demonstrated any attributable adverse events. CONCLUSIONS: No high-quality evidence demonstrates that prehospital services reduce falls in community-dwelling older adults. Screening by prehospital personnel using semistructured risk assessments appears feasible, but it is unclear whether this is superior to referral based on fall-related chief complaints. TRIAL REGISTRATION NUMBER: PROSPERO 2012:CRD42012002782.

Endovascular Thrombectomy for Anterior Circulation Stroke: Systematic Review and Meta-Analysis.

BACKGROUND AND PURPOSE: Stroke affects ≈700,000 patients annually. Recent randomized controlled trials comparing endovascular thrombectomy (ET) with medical therapy, including intravenous thrombolysis (IVT) with tissue-type plasminogen activator, have shown effectiveness of ET for some stroke patients. The study objective is to evaluate the effect of ET on good outcome in stroke patients. METHODS: We searched PubMed, Embase, Web of Science, SCOPUS, ClinicalTrials.gov, and Cochrane databases to identify original research publications between 1996 and 2015 that (1) reported clinical outcomes in patients for stroke at 90 days with the modified Rankin Scale; (2) included at least 10 patients per group; (3) compared outcome with a control arm, and (4) included anterior circulation strokes in each arm. Two authors reviewed articles for inclusion independently. RESULTS: Nine of 23 809 studies met inclusion criteria. In primary analysis, ET was associated with increased odds for good outcome (odds ratio [OR], 1.75; 95% confidence interval [CI], 1.20-2.54). In secondary analysis, younger patients (OR, 1.85; 95% CI, 1.50-2.28), older patients (OR, 1.93; 95% CI, 1.10-3.37), patients receiving intravenous thrombolysis (OR, 1.83; 95% CI, 1.46-2.31), patients with worse strokes (OR, 2.23; 95% CI, 1.56-3.18), and patients with more moderate strokes (OR, 1.72; 95% CI, 1.36-2.18) had increased odds for good outcome. Symptomatic intracranial hemorrhage and mortality were similar between ET and control patients. No evidence of publication bias was seen. CONCLUSIONS: ET improves good outcomes after anterior circulation stroke. ET should be strongly considered for all patients presenting within 6 hours of onset with a stroke affecting a proximal, anterior circulation vessel without a contraindication to ET.

Cause or Effect? Selective Serotonin Reuptake Inhibitors and Falls in Older Adults: A Systematic Review.

A 2012 update of the Beers criteria categorizes selective serotonin reuptake inhibitors (SSRIs) as potentially inappropriate medications in all older adults based on fall risk. The application of these recommendations, not only to frail nursing home residents, but to all older adults, may lead to changes in health policy or clinical practice with harmful consequences. A systematic review of studies on the association between SSRIs and falls in older adults was conducted to examine the evidence for causation. Twenty-six studies met the inclusion criteria. The majority of studies were observational and suggest an association between SSRIs and falls. The direction of the relationship--causation or effect--cannot be discerned from this type of study. Standardized techniques for determining likely causation were then used to see if there was support for the hypothesis that SSRIs lead to falls. This analysis did not suggest causation was likely. There is no Level 1 evidence that SSRIs cause falls. Therefore, changes in the current treatment guidelines or policies on the use of SSRIs in older adults based on fall risk may not be justified at this time given the lack of an established evidence base. Given its significance to public health, well-designed experimental studies are required to address this question definitively.

Outcome methods used in clinical studies of Chiari malformation Type I: a systematic review.

OBJECT: Chiari malformation Type I (CM-I) is a common and often debilitating neurological disease. Efforts to improve treatment of CM-I are impeded by inconsistent and limited methods of evaluating clinical outcomes. To understand current approaches and lay a foundation for future research, the authors conducted a systematic review of the methods used in original published research articles to evaluate clinical outcomes in patients treated for CM-I. METHODS: The authors searched PubMed, Embase, the Cumulative Index to Nursing and Allied Health Literature, ClinicalTrials.gov , and Cochrane databases to identify publications between January 2003 and August 2013 that met the following criteria: 1) reported clinical outcomes in patients treated for CM-I; 2) were original research articles; 3) included at least 10 patients or, if a comparative study, at least 5 patients per group; and 4) were restricted to patients with CM-I. RESULTS: Among the 74 papers meeting inclusion criteria, there was wide variation in the outcome methods used. However, all approaches were broadly grouped into 3 categories: 1) "gestalt" impression of overall symptomatic improvement (n=45 papers); 2) postoperative change in specific signs or symptoms (n=20); or 3) results of various standardized assessment scales (n=22). Among standardized scales, 11 general function measures were used, compared with 6 disease-specific tools. Only 3 papers used scales validated in patients with CM-I. To facilitate a uniform comparison of these heterogeneous approaches, the authors appraised articles in multiple domains defined a priori as integral to reporting clinical outcomes in CM-I. Notably, only 7 articles incorporated patient-response instruments when reporting outcome, and only 22 articles explicitly assessed quality of life. CONCLUSIONS: The methods used to evaluate clinical outcomes in CM-I are inconsistent and frequently not comparable, complicating efforts to analyze results across studies. Development, validation, and incorporation of a small number of disease-specific patient-based instruments will improve the quality of research and care of CM-I patients.

Depression, antidepressants, and bone health in older adults: a systematic review.

OBJECTIVES: To examine the association between depression, antidepressant use, and bone health in older adults and the implications for treatment. DESIGN: Systematic review. SETTING: All studies that measured depression or antidepressant exposure and bone mineral density (BMD). PARTICIPANTS: Adults aged 60 and older. MEASUREMENTS: Age, site of BMD measurement using dual-energy X-ray absorptiometry (DXA), measure of depression or depressive symptoms, association between BMD changes, and depression or antidepressant use. RESULTS: Nineteen observational studies met the final inclusion criteria; no experimental studies were found. Several cross-sectional and longitudinal studies found that depression or depressive symptoms were associated with a decrease in BMD. Few studies and only two longitudinal studies addressed the association between serotonin reuptake inhibitor (SRI) antidepressant use and a decrease in BMD and they had conflicting results. CONCLUSION: Depression and depressive symptoms are associated with low bone mass and accelerated bone loss in older adults; putative mechanisms underlying this relationship are discussed. There is insufficient evidence that SRI antidepressants adversely affect bone health. Thus, a change in current recommendations for the use of antidepressants in older adults is not justified at the present time. Given the high public health significance of this question, more studies are required to determine whether (and in whom) antidepressants may be deleterious for bone health.