Early colorectal cancer detection-Current and evolving challenges in evidence, guidelines, policy, and practices.

The understanding at the beginning of the last century that colorectal cancer began as a localized disease that progressed and became systemic, and that most colorectal cancer arose from adenomatous polyps gave rise to aggressive attempts at curative treatment and eventually attempts to detect advanced lesions before they progressed to invasive disease. In the last four decades, steadily greater uptake of screening has led to reductions in colorectal cancer incidence and mortality. However, the fullest potential of screening is not being met due to the lack of organized screening, where a systems approach could lead to higher rates of screening of average and high risk groups, higher quality screening, and prompt followup of adults with positive screening tests. ABSTRACT: Since the beginning of the 20th century, there has been a general understanding that colorectal cancer is a clonal disease that progresses from a localized stage with a favorable prognosis through progressively more advanced stages which have progressively worse prognosis. That understanding led first to determined efforts to detect and treat early stage symptomatic disease, and then to detect pre-symptomatic colorectal cancer and precursor lesions, where there was hope that the natural history of the disease could be arrested and the incidence and premature mortality of colorectal cancer averted. Toward the end of the last century, guidelines for colorectal cancer screening, growth in the number of technical options for screening, and a steady increase in the proportion of the adult population who attended screening contributed to the beginning of a significant decline in colorectal cancer incidence and mortality. Despite this progress, colorectal cancer remains the third leading cause of death among men and women in the United States. Screening for early detection of precursor lesions and localized cancer offers the single most productive opportunity to further reduce the burden of disease, and yet nearly four in five deaths from colorectal cancer are associated with having never been screened, not recently screened, or not followed up for an abnormal screening test. This simple observation is a call to action in all communities to apply existing knowledge to fulfill the potential to prevent avertable incidence and mortality.

Cost-effectiveness of Interventions to Manage Diabetes: Has the Evidence Changed Since 2008?

OBJECTIVE: To synthesize updated evidence on the cost-effectiveness (CE) of interventions to manage diabetes, its complications, and comorbidities. RESEARCH DESIGN AND METHODS: We conducted a systematic literature review of studies from high-income countries evaluating the CE of diabetes management interventions recommended by the American Diabetes Association (ADA) and published in English between June 2008 and July 2017. We also incorporated studies from a previous CE review from the period 1985-2008. We classified the interventions based on their strength of evidence (strong, supportive, or uncertain) and levels of CE: cost-saving (more health benefit at a lower cost), very cost-effective (≤$25,000 per life year gained [LYG] or quality-adjusted life year [QALY]), cost-effective ($25,001-$50,000 per LYG or QALY), marginally cost-effective ($50,001-$100,000 per LYG or QALY), or not cost-effective (>$100,000 per LYG or QALY). Costs were measured in 2017 U.S. dollars. RESULTS: Seventy-three new studies met our inclusion criteria. These were combined with 49 studies from the previous review to yield 122 studies over the period 1985-2017. A large majority of the ADA-recommended interventions remain cost-effective. Specifically, we found strong evidence that the following ADA-recommended interventions are cost-saving or very cost-effective: In the cost-saving category are 1) ACE inhibitor (ACEI)/angiotensin receptor blocker (ARB) therapy for intensive hypertension management compared with standard hypertension management, 2) ACEI/ARB therapy to prevent chronic kidney disease and/or end-stage renal disease in people with albuminuria compared with no ACEI/ARB therapy, 3) comprehensive foot care and patient education to prevent and treat foot ulcers among those at moderate/high risk of developing foot ulcers, 4) telemedicine for diabetic retinopathy screening compared with office screening, and 5) bariatric surgery compared with no surgery for individuals with type 2 diabetes (T2D) and obesity (BMI ≥30 kg/m2). In the very cost-effective category are 1) intensive glycemic management (targeting A1C <7%) compared with conventional glycemic management (targeting an A1C level of 8-10%) for individuals with newly diagnosed T2D, 2) multicomponent interventions (involving behavior change/education and pharmacological therapy targeting hyperglycemia, hypertension, dyslipidemia, microalbuminuria, nephropathy/retinopathy, secondary prevention of cardiovascular disease with aspirin) compared with usual care, 3) statin therapy compared with no statin therapy for individuals with T2D and history of cardiovascular disease, 4) diabetes self-management education and support compared with usual care, 5) T2D screening every 3 years starting at age 45 years compared with no screening, 6) integrated, patient-centered care compared with usual care, 7) smoking cessation compared with no smoking cessation, 8) daily aspirin use as primary prevention for cardiovascular complications compared with usual care, 9) self-monitoring of blood glucose three times per day compared with once per day among those using insulin, 10) intensive glycemic management compared with conventional insulin therapy for T2D among adults aged ≥50 years, and 11) collaborative care for depression compared with usual care. CONCLUSIONS: Complementing professional treatment recommendations, our systematic review provides an updated understanding of the potential value of interventions to manage diabetes and its complications and can assist clinicians and payers in prioritizing interventions and health care resources.

Supporting a Culture of Evidence-Based Policy: Federal Funding for Public Health Law Evaluation Research, 1985-2014.

OBJECTIVE: Law powerfully influences health and can be a critical tool for promoting population well-being. Evaluation research is needed to measure the health effects of law and guide policy making and implementation. The purpose of this study was to assess trends in National Institutes of Health (NIH) funding for scientific public health law research (PHLR). METHODS: Using data from the UberResearch NIH grant repository, we collected and coded all grants with a focus on health law between FY'85 and FY'14 and then analyzed the grants by funding agency and topic areas. RESULTS: Between FY'85 and FY'14, NIH funded 510 research grants on health policy making, the health effects of laws or enforcement practices. On average, 4 PHLR grants were funded annually with a median total funding of $545 956 (range: $2535-$44 052 300) and a median annual funding of $205 223 (range: $2535-$7 019 517). CONCLUSIONS: National Institutes of Health has supported important PHLR but not nearly to the extent necessary to ensure that public health laws affecting the population are evaluated in a rigorous and timely manner. In addition to greater funding evaluation research, NIH can increase its support for creating legal datasets, fund training in PHLR, and work with the National Library of Medicine to create Medical Subject Headings (MeSH) terms related to PHLR.

The History of Evidence-Based Practice in Nursing Education and Practice.

Beginning with Florence Nightingale in the 1800s and evolving again within the medical community, evidence-based practice continues to advance along with the nursing discipline. Evidence-based practice is foundational to undergraduate and graduate nursing education and is a way for the nursing discipline to minimize the theory to practice gap. This article discusses the concept of evidence-based practice from a historical perspective as it relates to nursing in the educational and practice domains. The concept evidence-based practice is defined, and the similarities and differences to evidence-based medicine are discussed. It is crucial that registered nurses be proactive in their quest for research knowledge, so the gap between theory and practice continues to close. Utilizing nursing best practice guidelines, reviewing and implementing applicable research evidence, and taking advantage of technological advances are all ways in which nursing can move forward as a well-informed discipline.

[Epidemiology, knowledge and practices: a critical analysis]. / Epidemiología, saberes y prácticas: un análisis crítico.

If research companies need to permanently review their theoretical foundations and objects of study, evidently epidemiology should also consider these demands to pursue a transdisciplinary dialogue, as required by the study of the Health-Disease process. This dialogue should begin with a critique of its theoretical and methodological assumptions. Here, we discuss the concept of causality in epidemiology, exploring the "notions system" that has served as an original matrix for knowledge and practice. We analyze its close links with clinical knowledge, its dominant empirical-analytical orientation with a particular view of "the social", and finally, we present some critiques of the casual-inferential model, which is key in contemporary epidemiology.

Si cada empresa de investigación necesita revisar permanentemente sus supuestos teóricos y su propio objeto de estudio, es evidente que, en el caso de la Epidemiología, estas demandas también deben estar presentes en el interés por un diálogo transdisciplinario, tal como requiere el estudio del proceso salud-enfermedad. Este diálogo debe comenzar con una crítica de sus supuestos teóricos y metodológicos. Aquí discutimos el concepto de causalidad en la epidemiología, explorando el "sistema de nociones" que sirvió, en su evolución, como una matriz original para su conocimiento y práctica. Analizamos sus estrechos vínculos con el conocimiento clínico, su orientación empírico-analítica dominante con su visión particular "de lo social".

Nursing history: from conformity to challenging practice.

Elizabeth Rosser, Deputy Dean (Education and Professional Practice) and Professor of Nursing at Bournemouth University, considers the lessons that the nursing profession has learned since its early days.

A conversation with Joseph Lau.

Dr. Joseph Lau is a world-leading expert in meta-analysis and systematic reviews. Currently a professor in the Department of Health Services, Policy and Practice and co-director of the Center for Evidence-based Medicine at Brown University, Professor Lau has applied evidence-based methods to a variety of clinical, biomedical and healthcare topics; has developed reliable and efficient methods and tools to conduct systematic reviews and meta-analyses; and has advanced an understanding on the impact of factors that may contribute to differences of results in scientific studies. His past research includes cumulative meta-analysis of randomized controlled trials, comparison of results from large trials and meta-analyses of small trials, effect of baseline risk in the interpretation of clinical trial results, and empirical evaluation of existing methods of combining data. His current focus is on a Web-based repository of systematic review data, reviews of diagnostic tests, nutrition, clinical practice guidelines, and dissemination of evidence-based methods to varied health-care disciplines. This report is a conversation from an adapted version of an interview, more or less chronologically arranged, between Joseph C. Cappelleri as interviewer and Joseph Lau as interviewee, with Meghan Ingerick recording and transcribing the interview.

Alice Magaw: a model for evidence-based practice.

The model of evidence-based practice (EBP) of Alice Magaw places the practice of nurse anesthesia as an early pioneer in patient safety and is prophetic to the aims of the Institute of Medicine (IOM). In its 2001 report, Crossing the Quality Chasm, the IOM identified 6 aims essential to improving the delivery of care. These aims include safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. Magaw used her vast expertise in anesthetic administration to develop protocols and a body of knowledge that could be used as a template for practitioners near and far. This early use of EBP principles places nurse anesthesia at the forefront of the model and the movement to provide high-quality care. Practitioners sought her practice model out as she demonstrated her techniques to visiting providers as well as through her published ideal anesthetics in the literature. She wrote, "Pioneers are noted for building upon a body of knowledge, establishing a model for continuous improvement, and exemplifying notable methods of research with subsequent documentation of their findings." Magaw exemplified the EBP model.

The early clinical x-ray in the United States: patient experiences and public perceptions.

The first x-ray machines were large, loud, sparking, smelly, and ostentatious devices, prone to mishap and injury even when fully under the control of the physicians who, in droves, invested money and prestige in them. Their bizarre and sometimes overwhelming presentation in the clinic reinforced the contemporary public understanding of x-rays as fantastically potent yet ambiguously helpful. As one of the icons of the new scientific medicine, x-rays bore much of the public's expectations for a technological panacea, a belief that was reinforced by the spectacle of their generation and their undeniable effect on the body. A quarter century later, refinement of the technology had made irradiation safer and more effective, but also made the operation of the machines themselves almost undetectable. This "domestication" of x-ray machines underscored their failure as a modern-day heroic medicine, while reinforcing an emergent understanding of radiation as a subtle, cumulative, and insidious threat.

Bt cotton and farmer suicides in India: an evidence-based assessment.

Bt cotton is accused of being responsible for an increase of farmer suicides in India. In this article, we provide a comprehensive review of evidence on Bt cotton and farmer suicides. Available data show no evidence of a 'resurgence' of farmer suicides. Moreover, Bt cotton technology has been very effective overall in India. Nevertheless, in specific districts and years, Bt cotton may have indirectly contributed to farmer indebtedness, leading to suicides, but its failure was mainly the result of the context or environment in which it was planted.

An asset-based approach to vulnerability: the case of small-scale fishing areas in Cameroon and Nigeria.

This paper analyses vulnerability to poverty of rural small-scale fishing communities using cross-section data from 295 households in Cameroon and 267 in Nigeria. We propose a vulnerability measure that incorporates the idea of asset poverty into the concept of expected poverty, which allows decomposing expected poverty into expected structural-chronic, structural-transient, and stochastic-transient poverty. The findings show that most households in our study areas are expected to be structurally-chronic and structurally-transient poor. This underlines the importance of asset formation for long-term poverty reduction strategies. Further refinements are possible with longitudinal data and information about future states of nature.