Inhaled short-acting bronchodilators for managing emergency childhood asthma: an overview of reviews.

International guidelines provide conflicting recommendations on how to use bronchodilators to manage childhood acute wheezing conditions in the emergency department (ED), and there is variation within and among countries in how these conditions are managed. This may be reflective of uncertainty about the evidence. This overview of systematic reviews (SRs) aimed to synthesize, appraise, and present all SR evidence on the efficacy and safety of inhaled short-acting bronchodilators to treat asthma and wheeze exacerbations in children 0-18 years presenting to the ED. Searching, review selection, data extraction and analysis, and quality assessments were conducted using methods recommended by The Cochrane Collaboration. Thirteen SRs containing 56 relevant trials and 5526 patients were included. Results demonstrate the efficacy of short-acting beta-agonist (SABA) delivered by metered-dose inhaler as first-line therapy for younger and older children (hospital admission decreased by 44% in younger children, and ED length of stay decreased by 33 min in older children). Short-acting anticholinergic (SAAC) should be added to SABA for older children in severe cases (hospital admission decreased by 27% and 74% when compared to SABA and SAAC alone, respectively). Continuous nebulization, addition of magnesium sulfate to SABA, and levosalbutamol compared to salbutamol cannot be recommended in routine practice.

Diagnostic thresholds for gestational diabetes and their impact on pregnancy outcomes: a systematic review.

AIMS: To assess different diagnostic thresholds for gestational diabetes on outcomes for mothers and their offspring in the absence of treatment for gestational diabetes. This information was used to inform a National Institutes of Health consensus conference on diagnosing gestational diabetes. METHODS: We searched 15 electronic databases from 1995 to May 2012. Study selection was conducted independently by two reviewers. Randomized controlled trials or cohort studies were eligible if they involved women without known pre-existing diabetes mellitus and who did not undergo treatment for gestational diabetes. One reviewer extracted, and a second reviewer verified, data for accuracy. Two reviewers independently assessed methodological quality. RESULTS: Thirty-eight studies were included. Three large, methodologically strong studies showed a continuous positive relationship between increasing glucose levels and the incidence of Caesarean section and macrosomia. When data were examined categorically (i.e. women meeting or not meeting specific diagnostic thresholds), women with gestational diabetes across all glucose criteria had significantly more Caesarean sections, shoulder dystocia, macrosomia (except for International Association of Diabetes in Pregnancy Study Groups' criteria) and large for gestational age. Higher glucose thresholds did not consistently demonstrate greater risk for all outcomes. CONCLUSIONS: Higher glucose thresholds did not consistently demonstrate greater risk, possibly because studies did not compare mutually exclusive groups of women. A pragmatic approach for diagnosis of gestational diabetes using Hyperglycemia and Adverse Pregnancy Outcome Study odds ratio 2.0 thresholds warrants further consideration until additional analysis of the data comparing mutually exclusive groups of women is provided and large randomized controlled trials investigating different diagnostic and treatment thresholds are completed.

Defining metabolically healthy obesity in children: a scoping review.

We conducted a scoping review to identify definitions of metabolically healthy obesity (MHO), describe gaps in the literature, and establish a universal definition of MHO in children. We searched electronic databases from January 1980 to June 2017 and grey literature. Experimental, quasi-experimental, or observational studies were eligible for inclusion if they (i) included a definition of MHO that identified risk factors, cut-off values, and the number of criteria used to define MHO, and (ii) classified 2-18 year olds as overweight or obese. Two reviewers independently screened 1,711 papers for relevance and quality; we extracted data from 39 individual reports that met inclusion criteria. Most (31/39; 79%) definitions of MHO included an absence of cardiometabolic risk factors. Heterogeneity across MHO definitions, obesity criteria, and sample sizes/characteristics resulted in variable prevalence estimates (3-80%). Finally, we convened an international panel of 46 experts to complete a 4-round Delphi process to generate a consensus-based definition of MHO. Based on consensus (≥ 80% agreement), our definition of MHO included: high density lipoprotein-cholesterol > 40 mg/dl (or > 1.03 mmol/l), triglycerides ≤ 150 mg/dl (or ≤ 1.7 mmol/l), systolic and diastolic blood pressure ≤ 90th percentile, and a measure of glycemia. This definition of MHO holds potential universal value to enable comparisons between studies and inform clinical decision-making for children with obesity.

Oral versus intravenous rehydration for treating dehydration due to gastroenteritis in children.

BACKGROUND: Dehydration associated with gastroenteritis is a serious complication. Oral rehydration is an effective and inexpensive treatment, but some physicians prefer intravenous methods. OBJECTIVES: To compare oral with intravenous therapy for treating dehydration due to acute gastroenteritis in children. SEARCH STRATEGY: We searched the Cochrane Infectious Diseases Group Specialized Register (March 2006), CENTRAL (The Cochrane Library 2006, Issue 1), MEDLINE (1966 to March 2006), EMBASE (1974 to March 2006), LILACS (1982 to March 2006), and reference lists. We also contacted researchers, pharmaceutical companies, and relevant organizations. SELECTION CRITERIA: Randomized and quasi-randomized controlled trials comparing intravenous rehydration therapy (IVT) with oral rehydration therapy (ORT) in children up to 18 years of age with acute gastroenteritis. DATA COLLECTION AND ANALYSIS: Two authors independently extracted data and assessed quality using the Jadad score. We expressed dichotomous data as a risk difference (RD) and number needed to treat (NNT), and continuous data as a weighted mean difference (WMD). We used meta-regression for subgroup analyses. MAIN RESULTS: Seventeen trials (1811 participants), of poor to moderate quality, were included. There were more treatment failures with ORT (RD 4%, 95% confidence interval (CI) 1 to 7, random-effects model; 1811 participants, 18 trials; NNT = 25). Six deaths occurred in the IVT group and two in the ORT groups (4 trials). There were no significant differences in weight gain (369 participants, 6 trials), hyponatremia (248 participants, 2 trials) or hypernatremia (1062 participants, 10 trials), duration of diarrhea (960 participants, 8 trials), or total fluid intake at six hours (985 participants, 8 trials) and 24 hours (835 participants, 7 trials). Shorter hospital stays were reported for the ORT group (WMD -1.20 days, 95% CI -2.38 to -0.02 days; 526 participants, 6 trials). Phlebitis occurred more often in the IVT group (NNT 50, 95% CI 25 to 100) and paralytic ileus more often in the ORT group (NNT 33, 95% CI 20 to 100, fixed-effect model), but there was no significant difference between ORT using the low osmolarity solutions recommended by the World Health Organization and IVT (729 participants, 6 trials). AUTHORS' CONCLUSIONS: Although no clinically important differences between ORT and IVT, the ORT group did have a higher risk of paralytic ileus, and the IVT group was exposed to risks of intravenous therapy. For every 25 children (95% CI 14 to 100) treated with ORT one would fail and require IVT.

Intravenous immunoglobulin for presumed viral myocarditis in children and adults.

BACKGROUND: Case reports and case series have described dramatic responses to IVIG in adults and children with presumed viral myocarditis. Administration of IVIG has become commonplace in the management of this condition. OBJECTIVES: To compare the outcome of patients with presumed viral myocarditis treated with IVIG to patients who did not receive IVIG. SEARCH STRATEGY: We searched CENTRAL (Issue 2, 2003), MEDLINE/PubMed (1966-2003), EMBASE (1988-2003), CINAHL (1982-2003), Web of Science (1975-2003), trials registries and conference proceedings. We contacted authors of trials and checked reference lists of relevant papers. SELECTION CRITERIA: Studies were included if: (1) patients had a clinical diagnosis of acute myocarditis with either a left ventricular ejection fraction (LVEF) <= 0.45, LVEDD of >2 SDs above the norm, or a shortening fraction (SF) >2 SDs below the mean and the duration of cardiac symptoms was less than six months; (2) patients had no evidence of non-infectious or bacterial cardiac disease; and, (3) patients were randomised to receive at least 1 gm/kg of IVIG versus no IVIG or placebo. Studies were excluded if: (1) patients had received immunosuppression prior to outcome assessment; or, (2) onset of myocarditis was less than six months postpartum. DATA COLLECTION AND ANALYSIS: Searches were screened and inclusion criteria applied independently by two reviewers. Quality was assessed by two reviewers using the Jadad scale and allocation concealment. Data were extracted independently by two reviewers. Meta-analysis was not possible because only one relevant study was found. MAIN RESULTS: The relevant study involved 62 adults with acute myocarditis randomized to receive IVIG or an equivalent volume of 0.1% albumin in a blinded fashion. The incidence of death or requirement for cardiac transplant or placement of a left ventricular assist device was low in both groups (OR for event-free survival was 0.52 ,95% CI 0.12 to 2.30). Follow-up at six and 12 months showed equivalent improvement in LVEF (mean difference 0.00, 95% CI -0.07 to 0.07 at six months, mean difference 0.01, 95% CI -0.06 to 0.08 at 12 months). Functional capacity as assessed by peak oxygen consumption was equivalent in the two groups at 12 months (mean difference -0.80, 95% CI -4.57 to 2.97). Infusion-related side effects were more common in the treated group, but all appeared to be mild (OR 30.16, 95% CI 1.69 to 539.42). AUTHORS' CONCLUSIONS: Evidence from one trial does not support the use of IVIG for the management of adults with presumed viral myocarditis. There are no randomized paediatric trials. Further studies of the pathophysiology of this entity would lead to improved diagnostic criteria which would facilitate future research.

Acyclovir for treating varicella in otherwise healthy children and adolescents.

BACKGROUND: Acyclovir has the potential to shorten the course of illness which may result in reduced costs and morbidity associated with chickenpox. OBJECTIVES: 1) To examine the evidence evaluating the efficacy of acyclovir in alleviating symptoms of chickenpox and shortening the duration of illness. 2) To examine complications of chickenpox and adverse effects associated with acyclovir as reported in the relevant trials. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 2, 2005), MEDLINE (January 1966 to June 2005), and EMBASE (1988 to June 2005). The reference lists of all relevant articles were reviewed. The primary author of relevant studies and the pharmaceutical company that manufactures acyclovir were contacted. SELECTION CRITERIA: Randomized controlled trials that evaluated otherwise healthy children zero to 18 years of age, with chickenpox. DATA COLLECTION AND ANALYSIS: Two authors independently reviewed the studies for eligibility. Two authors independently assessed methodological quality of the relevant studies using the Jadad scale and allocation concealment. Differences were resolved by consensus. Data were extracted by one author using a structured form and checked by a second. Continuous data were converted to the weighted mean difference (WMD). Weighted mean differences were combined into an overall estimate using random effects. There were too few studies to consider exploring statistical heterogeneity between studies (i.e., differences in reported effects), formally, or to assess for publication bias. MAIN RESULTS: Three studies were included. Study quality was three (n = 2) and four (n = 1) on the Jadad scale. Acyclovir was associated with a reduction in the number of days with fever (-1.1 days, 95% CI -1.3 to -0.9) and in reducing the maximum number of lesions (-76 lesions, -145 to -8). Results were less supportive with respect to the number of days to no new lesions and the number of days to the relief of itching. There were no clinically important differences between acyclovir and placebo with respect to complications associated with chickenpox or adverse effects associated with the treatment. AUTHORS' CONCLUSIONS: Acyclovir appears to be effective in reducing the number of days with fever and the maximum number of lesions among otherwise healthy children with chickenpox. The results were less convincing with respect to the number of days to no new lesions and relief of itchiness. The clinical importance of acyclovir treatment in otherwise healthy children remains uncertain.

The effect of the tricyclic antidepressant drug, nortriptyline on left ventricular ejection fraction and left ventricular volumes.

Eight patients with major depression but otherwise healthy underwent radionuclide cardiography before and during nortriptyline treatment. The second examination was performed when the nortriptyline plasma concentration was within the therapeutic range (60-150 micrograms X l-1). Heart rate, arterial blood pressure, left ventricular ejection fraction, left ventricular volumes, systolic pressure-volume ratio, and cardiac output were determined. Heart rate increased in mean by 13% (P less than 0.05). All other variables were unchanged. We conclude that nortriptyline in therapeutic doses produces no major adverse effect on left ventricular function. Routine radionuclide cardiography might be a suitable method to detect among those treated with tricyclic antidepressants the occasional susceptible patient. This may particularly apply to patients with known heart disease and to elderly patients.

Gender differences in the occurrence of farm related injuries.

AIMS: To use national surveillance data in Canada to describe gender differences in the pattern of farm fatalities and severe injuries (those requiring hospitalisation). METHODS: Data from the Canadian Agricultural Injury Surveillance Program (CAISP) included farm work related fatalities from 1990 to 1996 for all Canadian provinces and abstracted information from hospital discharge records from eight provinces for the five fiscal years of 1990 to 1994. Gender differences in fatalities and injuries were examined by comparison of proportions and stratified by sex, injury class (machinery, non-machinery), and age group. RESULTS: Over the six year period of 1990 to 1996 there were approximately 11 times as many agriculture related fatalities for males compared to females (655 and 61, respectively). The most common machinery mechanisms of fatal injuries were roll-over (32%) for males and run-over (45%) for females. Agricultural machinery injuries requiring hospitalisation showed similar patterns, with proportionally more males over age 60 injured. The male:female ratio for non-machinery hospitalisations averaged 3:1. A greater percentage of males were struck by or caught against an object, whereas for females, animal related injuries predominated. CONCLUSIONS: Gender is an important factor to consider in the interpretation of fatal and non-fatal farm injuries. A greater number of males were injured, regardless of how the occurrence of injury was categorised, particularly when farm machinery was involved. As women increasingly participate in all aspects of agricultural production, there is a need to collect, interpret, and disseminate information on agricultural injury that is relevant for both sexes.

Epinephrine for bronchiolitis.

BACKGROUND: Bronchodilators are commonly used in the management of bronchiolitis. A recent systematic review showed that bronchodilators produce modest short-term benefit among patients with mild or moderate bronchiolitis. OBJECTIVES: To compare epinephrine versus placebo and other bronchodilators in infants less than 2 years of age with bronchiolitis. SEARCH STRATEGY: Electronic searches were conducted on the following bibliographic databases: The Cochrane Central Register of Controlled Trials (CENTRAL) (issue 1, 2003), MEDLINE (January 1966 to May 2003), and EMBASE (January 1988 to May 2003). The reference lists of all selected articles were examined for relevant studies. Primary authors were contacted for information on additional trials. SELECTION CRITERIA: Studies were included if they: 1) were RCTs comparing epinephrine with placebo or other bronchodilator; 2) involved children less than two years with bronchiolitis; 3) presented at least one quantitative outcome. DATA COLLECTION AND ANALYSIS: Searches were screened and inclusion criteria applied independently by two reviewers. Quality was assessed by two reviewers using the Jadad scale and allocation concealment. Data were extracted by one reviewer using a structured form and checked by a second. Separate analyses were conducted for the two types of control groups (placebo, non-epinephrine bronchodilators) and for patient status (inpatient, outpatient). MAIN RESULTS: Fourteen studies were included. Quality ranged from one to five (Jadad scale) with a median of three (inter-quartile range: two to three). Allocation concealment was adequate in six trials and unclear in eight. Among inpatient studies comparing epinephrine and placebo (n = five), there was one significant outcome favouring epinephrine: change in clinical score at 60 minutes post-treatment (SMD -0.52; 95% CI -1.00,-0.03). For outpatient studies (n = three), change in clinical score at 60 minutes (SMD -0.81; -1.56,-0.07), change in oxygen saturation at 30 minutes (WMD 2.79;1.50,4.08), respiratory rate at 30 minutes (WMD -4.54;-8.89-0.19), and "improvement" (OR 25.06; 4.95,126.91) favoured epinephrine. Heart rate at 60 minutes post-treatment favoured placebo (WMD 11.80; 5.20,18.40). Admission rates and change in oxygen saturation at 60 minutes post-treatment were not significantly different. For inpatient studies comparing epinephrine and salbutamol (n = four), only one of the seven outcomes was statistically significant: respiratory rate at 30 minutes favoured epinephrine (WMD -5.12; -6.83;-3.41). Among outpatient studies (n = four), change in oxygen saturation at 60 minutes (WMD 1.91; 0.38,3.44), heart rate at 90 minutes (WMD -14.00; -22.95;-5.05), respiratory rate at 60 minutes (WMD -7.76; -11.35,-4.17) post-treatment and "improvement" (OR 4.51; 1.93,10.53) favoured epinephrine. Admission rates were not significantly different (OR 0.40; 0.12,1.33). Pallor at 30 minutes post-treatment was significantly higher in the epinephrine group (OR 6.00; 1.33,27.00). REVIEWER'S CONCLUSIONS: There is insufficient evidence to support the use of epinephrine for the treatment of bronchiolitis among inpatients. There is some evidence to suggest that epinephrine may be favourable to salbutamol and placebo among outpatients. A number of large, multi-centered trials are required to examine the effectiveness of epinephrine compared to placebo and salbutamol for infants presenting to outpatient settings. There is a need to develop a validated, reliable scoring system that is sensitive to important clinical changes in patients with bronchiolitis.

Acyclovir for treating varicella in otherwise healthy children and adolescents.

BACKGROUND: Acyclovir has the potential to shorten the course of illness which may result in reduced costs and morbidity associated with chickenpox. OBJECTIVES: 1) To examine the evidence evaluating the efficacy of acyclovir in alleviating symptoms of chickenpox and shortening the duration of illness. 2) To examine complications of chickenpox and adverse effects associated with acyclovir as reported in the relevant trials. SEARCH STRATEGY: We searched The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 1, 2003), MEDLINE (January 1966 to May 2003), and EMBASE (1988 to April 2003). The reference lists of all relevant articles were reviewed. The primary author of relevant studies and the pharmaceutical company that manufactures acyclovir were contacted. SELECTION CRITERIA: Randomized controlled trials that evaluated otherwise healthy children zero to 18 years of age, with chickenpox. DATA COLLECTION AND ANALYSIS: Two reviewers independently reviewed the studies for eligibility. Two reviewers independently assessed methodological quality of the relevant studies using the Jadad scale and allocation concealment. Differences were resolved by consensus. Data were extracted by one reviewer using a structured form and checked by a second.Continuous data were converted to the weighted mean difference (WMD). Weighted mean differences were combined into an overall estimate using random effects. There were too few studies to consider exploring statistical heterogeneity between studies (i.e., differences in reported effects), formally, or to assess for publication bias. MAIN RESULTS: Three studies were included. Study quality was three (n = 2) and four (n = 1) on the Jadad scale. Acyclovir was associated with a reduction in the number of days with fever (-1.1 days, 95% CI -1.3 to -0.9) and in reducing the maximum number of lesions (-76 lesions, -145 to -8). Results were less supportive with respect to the number of days to no new lesions and the number of days to the relief of itching. There were no clinically important differences between acyclovir and placebo with respect to complications associated with chickenpox or adverse effects associated with the treatment. REVIEWERS' CONCLUSIONS: Acyclovir appears to be effective in reducing the number of days with fever and the maximum number of lesions among otherwise healthy children with chickenpox. The results were less convincing with respect to the number of days to no new lesions and relief of itchiness. The clinical importance of acyclovir treatment in otherwise healthy children remains controversial.

Acyclovir for treating varicella in otherwise healthy children and adolescents.

BACKGROUND: Acyclovir has the potential to shorten the course of illness which may result in reduced costs and morbidity. OBJECTIVES: 1) To examine the evidence evaluating the efficacy of acyclovir in alleviating symptoms and shortening the duration of illness. 2) To examine complications of chickenpox and adverse effects associated with acyclovir as reported in the relevant trials. SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register (2002, Issue 2), MEDLINE (January 1966 to October 2001), EMBASE (1988 to September 2001). The reference lists of all relevant articles were reviewed. The primary author of relevant studies and the pharmaceutical company that manufactures acyclovir were contacted. SELECTION CRITERIA: Randomized controlled trials that evaluated otherwise healthy children 0-18 years of age with chickenpox. DATA COLLECTION AND ANALYSIS: Two reviewers independently reviewed the studies for eligibility. Two reviewers independently assessed methodological quality of the relevant studies using the Jadad scale and allocation concealment. Differences were resolved by consensus. Data were extracted by one reviewer using a structured form and checked by a second. Continuous data were converted to the weighted mean difference (WMD). Weighted mean differences were not combined into an overall estimate due to the varied age groups between studies. There were too few studies to consider statistical heterogeneity between studies (i.e., differences in reported effects), to perform subgroup or sensitivity analyses, or to assess for publication bias. MAIN RESULTS: Three studies were included. Study quality was three (n=2) and four (n=1) on the Jadad scale. Acyclovir was associated with a reduction in the number of days with fever, from -1.0 (95% CI -1.5,-0.5) to -1.3 (95% CI -2.0,-0.6). Results were inconsistent with respect to the number of days to no new lesions, the maximum number of lesions and the number of days to the relief of itching. There were no clinically important differences between acyclovir and placebo with respect to complications associated with chickenpox or adverse effects associated with the drug. REVIEWER'S CONCLUSIONS: Acyclovir appears to be effective in reducing the number of days with fever among otherwise healthy children with chickenpox. The results were inconsistent with respect to the number of days to no new lesions, relief of itchiness and maximum number of lesions. The clinical importance of acyclovir treatment in otherwise healthy children remains controversial.

Glucocorticoids for croup.

BACKGROUND: Since the initial version of this systematic review in 1997, a number of randomised trials examining the benefit of glucocorticoids have been published, reflecting a continued interest in the use of glucocorticoids to treat patients with croup. The objective of this review was to provide evidence to guide clinicians in their treatment of patients with croup by determining the effectiveness of glucocorticoids and to identify areas of uncertainty for future research. OBJECTIVES: To determine the effect of glucocorticoids for children with croup. SEARCH STRATEGY: We searched The Cochrane Central Register of Controlled Trials (CENTRAL) (issue 1, 2003), MEDLINE (January 1966 to April 2003) and Excerpta Medica/EMBASE (January 1974 to August 2003). We also contacted authors of identified croup trials published in the last ten years to inquire about additional published or unpublished trials. SELECTION CRITERIA: Randomised controlled trials that examine children with croup and objectively measure the effectiveness of glucocorticoid treatment. DATA COLLECTION AND ANALYSIS: Based on review of the title and abstract (when available), two researchers identified studies for potential relevance. The complete text was retrieved and using a priori inclusion criteria, the studies were independently reviewed for relevance by two reviewers. Two observers independently assessed quality. Differences with respect to inclusion status and quality assessment were resolved by consensus. Data were extracted using a structured form by one reviewer and checked for accuracy by a second reviewer. Standard statistical analyses were performed. MAIN RESULTS: Thirty-one studies were deemed relevant for inclusion (N = 3736). Glucocorticoid treatment was associated with an improvement in the Westley score at six hours with a weighted mean difference of -1.2 (95% confidence interval -1.6 to -0.8) and at 12 hours -1.9 (-2.4 to -1.3); at 24 hours this improvement was no longer significant (-1.3, -2.7 to 0.2). Fewer return visits and/or (re)admissions occurred in patients treated with glucocorticoids (relative risk 0.50; 0.36 to 0.70). Length of time spent in accident and emergency or hospital (weighted mean difference 12 hours, five to 19 hours) was significantly decreased for patients treated with glucocorticoids. Use of epinephrine decreased for children treated with a glucocorticoid (risk difference 10%; 1 to 20). No other decreases in additional treatments were found in the primary analysis. Publication bias does not impact results importantly. No between-trial significant differences were found between populations with mild and moderate croup. Oral dexamethasone may be superior to intramuscular dexamethasone. REVIEWER'S CONCLUSIONS: Dexamethasone and budesonide are effective in relieving the symptoms of croup as early as six hours after treatment. Fewer return visits and/or (re)admissions are required and the length of time spent in hospital is decreased in inpatients. Dexamethasone is also effective in mild croup populations. Research is required to examine the most beneficial method for disseminating croup practice guidelines and to increase the uptake of evidence to improve outcomes.

Graduated driver licensing for reducing motor vehicle crashes among young drivers.

BACKGROUND: Graduated driver licensing (GDL) has been proposed as a means of reducing crash rates among novice drivers by gradually introducing them to higher risk driving situations. OBJECTIVES: To examine the effectiveness of GDL systems in reducing crash rates of young drivers. SEARCH STRATEGY: Studies were identified through searches of MEDLINE, EMBASE, CINAHL, Healthstar, Web of Science, NTIS Bibliographic Database, TRIS Online, SIGLE, the World Wide Web, relevant conference proceedings, consultation with experts and authors, and reference lists. The search was not restricted by language or publication status. SELECTION CRITERIA: Studies were included if: 1) they compared outcomes pre- and post-implementation of a GDL program within the same jurisdiction, 2) comparisons were made between jurisdictions with and without GDL, or 3) both. Studies had to report at least one objective, quantified outcome. Two reviewers independently screened searches and assessed the full text of potentially relevant studies for inclusion using a standard form. DATA COLLECTION AND ANALYSIS: Data were extracted by one reviewer and checked by a second. Additional data were requested from authors. Results were not pooled due to substantial heterogeneity between studies. Percentage change was calculated for each year after the intervention, using one year prior to the intervention as the baseline rate. Results were adjusted by internal controls. Analyses were stratified by different denominators (population, licensed drivers). Results were calculated for the different crash types (overall, injury, fatal, night-time, alcohol, and those resulting in hospitalization). Results were presented for 16 year-olds alone and all teenage drivers combined. MAIN RESULTS: We included 13 studies evaluating 12 GDL programs that were implemented between 1979 and 1998 in the US (n=7), Canada (3), New Zealand (1), and Australia (1). Programs varied in their restrictions during the intermediate stage: e.g. night curfews (8); limitations of extra passengers (2); roadway restrictions (1). Based on the Insurance Institute for Highway Safety classification scheme, no programs were good, six were acceptable, five were marginal, and one was poor. Reductions in crash rates were seen in all jurisdictions and for all crash types. Among 16 year-old drivers, the median decrease in per population overall crash rates during the first year was 31% (range 26-41%). Per population injury crash rates were similar (median 28%, range 4-43%). Results for all teenage drivers, rates per licensed driver, and rates adjusting for internal controls were generally reduced when comparing within jurisdictions. REVIEWERS' CONCLUSIONS: The existing evidence shows that GDL is effective in reducing the crash rates of young drivers, although the magnitude of the effect is unclear. The conclusions are supported by consistent direction of the findings, and the temporal relationship and plausibility of the association. The reviewers have made recommendations for primary research on GDL (e.g. study methods, standardized reporting of outcomes and results, long-term follow-up). The project has also shown what is needed to carry out systematic reviews of observational studies (e.g. quality assessment instruments).

Tissue adhesives for traumatic lacerations in children and adults.

BACKGROUND: Tissue adhesives have been used for many years to close simple lacerations as an alternative to standard wound closure (sutures, staples, adhesive strips). They offer many potential advantages over standard wound closure, including ease of use, decrease in pain and time to apply, as well as not requiring a follow-up visit for removal. Many studies have compared tissue adhesives and standard wound closure to determine the cosmetic outcome as well as these other secondary outcomes in their respective study populations. However, due to the wide variation in study parameters, there are no generalisable, definitive answers about the effectiveness of tissue adhesives. No study has been adequately powered to assess differences in complications, which are rare. OBJECTIVES: To summarize the best available evidence for the effect of tissue adhesives in the management of traumatic lacerations in children and adults. SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register (CD ROM 2001 Issue 4), the Cochrane Wounds Group Specialized Trials Register (Nov 2001), MEDLINE (1966 to Oct 1, 2001), and EMBASE (1988 to Sept 1, 2001) for relevant randomised controlled trials (RCTs). We also searched the citations of selected studies, and we contacted relevant authors and manufacturers of tissue adhesives to inquire about other published and unpublished trials. SELECTION CRITERIA: We included RCTs comparing tissue adhesives versus standard wound closure or tissue adhesive versus tissue adhesive for acute, linear, low tension, traumatic lacerations in an emergency or primary care setting. Trials evaluating tissue adhesives for surgical incisions or other types of wounds were not considered. DATA COLLECTION AND ANALYSIS: Data from eligible studies were extracted by one reviewer and checked for accuracy by a second reviewer. Two reviewers independently assessed masked copies for quality. Outcomes of cosmesis (subgroups of age, wound location and need for deep sutures), pain, procedure time, ease of use and complications were analysed separately for two comparisons: 1) tissue adhesive versus standard wound care; and 2) tissue adhesive versus tissue adhesive. MAIN RESULTS: Eight studies compared a tissue adhesive with standard wound care. No significant difference was found for cosmesis at any of the time points examined, using either Cosmetic Visual Analogue Scale (CVAS) or Wound Evaluation Score (WES). Data were only available for subgroup analysis for age; no significant differences were found. Pain scores (Parent VAS WMD -15.7 mm; 95% CI -21.9, -9.5) and procedure time (WMD -5.6 minutes; 95% CI -8.2, -3.1) significantly favoured tissue adhesives. No studies reported on ease of use. Small but statistically significant risk differences were found for dehiscence (favouring standard wound care NNH 25 95% CI 14, 100) and erythema (favouring tissue adhesive NNH 8 95% CI 4, 100). Other complications were not significantly different between treatment groups. Only one study was identified that compared two tissue adhesives (butylcyanoacrylate (Histoacryl TM) versus octylcyanoacrylate (Dermabond TM)) for pediatric facial lacerations. No significant difference was found for cosmesis using CVAS at 1-3 months, or using WES at 5-14 days and 1-3 months. Similarly, no significant difference was found in pain, procedure time or complications. Results for ease of use were incomplete as reported. REVIEWER'S CONCLUSIONS: Tissue adhesives are an acceptable alternative to standard wound closure for repairing simple traumatic lacerations. There is no significant difference in cosmetic outcome between tissue adhesives and standard wound closure, or between different tissue adhesives. They offer the benefit of decreased procedure time and less pain, compared to standard wound closure. A small but statistically significant increased rate of dehiscence with tissue adhesives must be considered when choosing the closure method (NNH 25).

Prognostic value of the Quebec Classification of Whiplash-Associated Disorders.

STUDY DESIGN: Retrospective cohort. OBJECTIVES: 1) Evaluate the utility of the Québec Classification of Whiplash-Associated Disorders as an initial assessment tool; 2) assess its ability to predict persistence of symptoms at 6, 12, 18, and 24 months postcollision; 3) examine one potential modification to the Classification. SUMMARY OF BACKGROUND DATA: In 1995, a task force from Québec, Canada, developed the Québec Classification of Whiplash-Associated Disorders to assist health care workers in making therapeutic decisions. The Classification was applied to an inception cohort of patients presenting for emergency medical care following their involvement in a rear-end motor vehicle collision. METHODS: All patients (n = 446) presenting to the only two emergency departments serving Kingston, Ontario, between October 1, 1995 and March 31, 1998 were considered for inclusion in the study. Eligible patients (n = 380) were categorized according to the Classification based on signs and symptoms documented in their emergency medical chart. Attempts were made to interview all patients shortly following and again 6 months after their collision. Patients were contacted at 12, 18, and 24 months postinjury only if sufficient time had elapsed between recruitment into and cessation of the study. Data were gathered regarding symptoms, treatments received, effects on usual activities, crash circumstances, and personal factors. Associations between initial Classification grade and the frequency/intensity of follow-up symptoms were quantified via multivariable analyses. RESULTS: The Classification was prognostic in that risk for Whiplash-Associated Disorders at 6, 12, 18, and 24 months increased with increasing grade. Analyses supported modification of the Classification to distinguish between Grade II cases of Whiplash-Associated Disorders with normal or limited range of motion. The greatest risk for long-term symptoms was seen among the group of patients with both point tenderness and limited range of motion. CONCLUSION: The analyses of this study support the use of the Québec Classification of Whiplash-Associated Disorders as a prognostic tool for emergency department settings, and the authors propose a modification of the Classification using a subdivision of the Grade II category.

The injury experience observed in two emergency departments in Kingston, Ontario during 'ice storm 98'.

OBJECTIVES: 1) To describe patterns of unintentional injury presenting for emergency medical care in Kingston, Ontario following the ice storm in January 1998; and 2) to provide recommendations for prevention during such situations. METHODS: Unintentional injuries related to the ice storm that presented at the two emergency departments in Kingston, Ontario were identified and described. RESULTS: A total of 254 injuries were identified. Injuries peaked the day following the onset of the ice storm and again 4-6 days following the storm. Common sources of injury included slips and falls on the ice (56%), activities related to clearing brush or trees (15%), and unintentional carbon monoxide poisonings (9%). CONCLUSIONS: While the number of injuries that presented during the storm and its aftermath was not unusual, the distribution of injuries by type did reflect the irregular nature of environmental conditions. This analysis provides useful information for public officials to use reviewing disaster plans and to generate recommendations for managing future occurrences.

Clinical observations of adult intercountry adoptees and their adoptive parents.

This article presented data from interviews with 29 adult foreign-born adoptees and 23 adoptive parents, highlighting M.S.W. students' impressions of the interviewees' responses. The students' main observations stressed individualizing adoptees and their families, cautioning against falling into the all-too-easy trap of self-fulfilling labeled behavior. A second theme was the importance of each social worker's own sensitivity and attitudes toward this type of racial mixing, and emphasized professional and personal self-awareness.

StaR Child Health: developing evidence-based guidance for the design, conduct, and reporting of pediatric trials.

Standards for Research in (StaR) Child Health was founded in 2009 to address the paucity and shortcomings of pediatric clinical trials. This initiative involves international experts who are dedicated to developing practical, evidence-based standards to enhance the reliability and relevance of pediatric clinical research. Through a systematic "knowledge to action" plan, StaR Child Health will make efforts to improve and expand the evidence base for child health across the world.