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Mental health literacy in primary care: Canadian Research and Education for the Advancement of Child Health (CanREACH). 初级保健中的心理健康素养:加拿大促进儿童健康的研究和教育(CanREACH)。
Pub Date : 2017-08-01 Epub Date: 2017-07-22 DOI: 10.1136/ebmed-2017-110714
Eden S N McCaffrey, Samuel Chang, Geraldine Farrelly, Abdul Rahman, David Cawthorpe

The effectiveness of a continuing education programme in paediatric psychopharmacology designed for primary healthcare providers was objectively measured based on the assumption that training would lead to measurable changes in referral patterns and established clinical measures of referred patients. Using established, valid and reliable measures of clinical urgency embedded in to a regional healthcare system since 2002, the referrals to child and adolescent psychiatric services of physicians who participated in the training (n=99) were compared pretraining and post-training, and to non-participating/untrained referring physicians (n=7753) making referrals over the same time period. Referrals were analysed for evidence of change based on frequencies and measures of clinical urgency. Participants of the training programme also completed standardised baseline and outcome self-evaluations. Congruent with participants self-reported evaluative reports of improved knowledge and practice, analysis of referral frequency and the clinical urgency of referrals to paediatric psychiatric services over the study period indicated that trained physicians made more appropriate referrals (clinically more severe) and reduced referrals to emergency services. Quantitative clinical differences as completed by intake clinicians blind to referrals from the study group designations were observed within the trained physician group pretraining and post-training, and between the trained physician group and the unexposed physician group. The results illustrate a novel model for objectively measuring change among physicians based on training in paediatric mental health management.

为初级保健提供者设计的儿科精神药理学继续教育方案的有效性是客观衡量的,其基础假设是培训将导致转诊模式的可衡量变化和转诊患者的既定临床措施。自2002年以来,使用已建立的、有效的、可靠的临床紧急措施嵌入到区域医疗保健系统中,比较了参加培训的医生(n=99)在培训前和培训后转诊到儿童和青少年精神科服务的情况,并与同期未参加/未接受培训的转诊医生(n=7753)进行了比较。根据频率和临床急迫性措施分析转诊的变化证据。培训方案的参与者还完成了标准化的基线和结果自我评价。与参与者自我报告的关于知识和实践改进的评估报告一致,对研究期间转介到儿科精神科服务的频率和临床紧迫性的分析表明,经过培训的医生进行了更适当的转诊(临床上更严重),并减少了转介到急诊服务的次数。在训练有素的医生组训练前和训练后,以及训练有素的医生组和未暴露的医生组之间,通过对研究组指定的转诊不知情的摄入临床医生完成的定量临床差异被观察到。结果说明了一个新的模型,客观地衡量变化的医生在儿科心理健康管理培训的基础上。
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引用次数: 18
Use of the M-CHAT follow-up interview (M-CHAT/F) by paediatricians during well-child care visits is feasible, valid and reliable. 儿科医生在儿童保健访问期间使用M-CHAT随访访谈(M-CHAT/F)是可行、有效和可靠的。
Pub Date : 2017-08-01 Epub Date: 2017-06-29 DOI: 10.1136/ebmed-2016-110654
Thyde Dumont-Mathieu
Citation: Sturner R, Howard B, Bergmann P, et al . Autism screening with online decision support by primary care pediatricians aided by M-CHAT/F. Pediatrics . 2016 Sep;138: e20153036.Early identification of children with autism spectrum disorders (ASDs) leads to early intervention and improved outcomes.1 The American Academy of Pediatrics (AAP) recommends universal screening with a validated tool such as the Modified Checklist for Autism in Toddlers (M-CHAT) at well-child care visits.2 The M-CHAT/R (original M-CHAT and its revised version) includes a follow-up interview (the M-CHAT/R-F) designed to clarify positive responses. Use of the M-CHAT/R-F significantly improves the positive predictive value (PPV) of the tool,3 but questions remain regarding the feasibility of using the interview in routine clinical care.The study investigated the feasibility of using the follow-up interview in routine practice …
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引用次数: 1
Apixaban may have lower risk of GI bleeding compared with dabigatran and rivaroxaban in patients with atrial fibrillation. 与达比加群和利伐沙班相比,阿哌沙班在房颤患者中可能具有较低的胃肠道出血风险。
Pub Date : 2017-08-01 Epub Date: 2017-07-13 DOI: 10.1136/ebmed-2017-110764
José Miguel Rivera-Caravaca, Gregory Y H Lip
Commentary on: Abraham NS, Noseworthy PA, Yao X, et al . Gastrointestinal safety of direct oral anticoagulants: a large population-based study. Gastroenterology 2017;152:1014–1022.e1.Oral anticoagulation (OAC) reduces the risk of stroke and mortality in atrial fibrillation (AF). The known limitations of vitamin K antagonists (VKAs) have led to the development of non-vitamin K oral anticoagulants (NOACs), including dabigatran, rivaroxaban, apixaban and edoxaban. These anticoagulants are at least as effective as VKAs for prevention of stroke in patients with AF and safer in terms of serious bleeding events.1–3 Given that high rates of gastrointestinal (GI) bleeding have been observed in NOACs,1 Abraham et al report a ‘real world’ study of the GI safety profile comparing the various NOACs head-to-head.Abraham et al enrolled both inpatients and outpatients with non-valvular AF who started dabigatran, apixaban or rivaroxaban during 1 October 2010 to 28 February 2015 from the Optum Labs Data …
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引用次数: 2
The Cochrane Collaboration withdraws a review on methylphenidate for adults with attention deficit hyperactivity disorder. Cochrane协作撤回了一篇关于哌甲酯治疗成人注意缺陷多动障碍的综述。
Pub Date : 2017-08-01 Epub Date: 2017-07-13 DOI: 10.1136/ebmed-2017-110716
Kim Boesen, Luis Carlos Saiz, Juan Erviti, Ole Jakob Storebø, Christian Gluud, Peter C Gøtzsche, Karsten Juhl Jørgensen

A Cochrane systematic review on immediate-release methylphenidate for adults with attention deficit hyperactivity disorder (ADHD) was withdrawn from the Cochrane Library on 26 May 2016 after substantial criticism of its methods and flawed conclusions. Retraction of scientific papers on this basis is unusual but can be necessary. We provide a summary of the criticism that led to the withdrawal. We detail the methodological flaws of the withdrawn Cochrane systematic review and general issues of bias and shortcomings of the included ADHD trials: cross-over designs compared with parallel-group designs, exclusion of participants with psychiatric comorbidity, absence of 'functional outcomes' and use of clinical outcomes with limited relevance, short trial duration and small trial populations, broken blinding caused by easily recognisable side effects, combining outcome assessments by trial investigators and participants, outcome reporting bias, poor evaluation of cardiovascular and psychiatric harms and conflicts of interest of trialists and systematic reviewers. The withdrawal of the Cochrane systematic review signals recognition of previous unreliable clinical ADHD research. We conclude that clinical trials of immediate-release methylphenidate in adults with ADHD are of very low quality. We urgently need well-conducted long-term trials free of bias to assess the benefits and harms of central stimulant treatment in adult ADHD.

2016年5月26日,一篇关于哌醋甲酯即刻释放治疗成人注意力缺陷多动障碍(ADHD)的Cochrane系统综述在其方法和有缺陷的结论遭到大量批评后从Cochrane图书馆撤回。在此基础上撤回科学论文是不寻常的,但可能是必要的。我们对导致撤军的批评进行了总结。我们详细介绍了撤回的Cochrane系统综述的方法学缺陷,以及纳入的ADHD试验的偏倚和缺点的一般问题:与平行组设计比较的交叉设计,排除有精神合并症的参与者,缺乏“功能结果”和使用相关性有限的临床结果,试验持续时间短,试验人群小,由容易识别的副作用引起的破碎盲法,结合试验研究者和参与者的结果评估,结果报告偏倚,对心血管和精神危害的不良评价以及试验人员和系统审稿人的利益冲突。Cochrane系统综述的退出标志着对先前不可靠的ADHD临床研究的认可。我们的结论是,哌醋甲酯即刻释放治疗成人ADHD的临床试验质量很低。我们迫切需要进行良好的、无偏见的长期试验,以评估中枢兴奋剂治疗成人多动症的利与弊。
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引用次数: 19
Percutaneous coronary intervention has similar 5-year survival rates to coronary artery bypass grafting surgery for patients with unprotected left main artery disease. 经皮冠状动脉介入治疗与无保护左主干疾病患者冠状动脉搭桥术的5年生存率相似。
Pub Date : 2017-08-01 Epub Date: 2017-07-06 DOI: 10.1136/ebmed-2017-110682
Carlos Collet, Patrick W Serruys
Commentary on: Makikallio T, Holm NR, Lindsay M, et al . Percutaneous coronary angioplasty versus coronary artery bypass grafting in treatment of unprotected left main stenosis (NOBLE): a prospective, randomised, open-label, non-inferiority trial. Lancet 2016;388:2743–2752.An on-going debate is whether percutaneous coronary intervention (PCI) offers similar clinical results compared with coronary artery bypass grafting surgery (CABG) for patients with unprotected left main artery disease (ULMAD). Previously, the SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery  (SYNTAX) trial scrutinized the benefit of the first generation of drug-eluting stents in patients with multivessel disease and ULMAD. At 5 years, CABG was associated with improved clinical outcomes compared with PCI. Nonetheless, in patients with ULMAD and SYNTAX score <33, similar results were observed.1 The European and American guidelines agree upon the fact that in patients with ULMAD, CABG is the preferred treatment whereas PCI might be an alternative when the SYNTAX score …
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引用次数: 0
Guidelines for reporting meta-epidemiological methodology research. 报告元流行病学方法学研究的指南。
Pub Date : 2017-08-01 Epub Date: 2017-07-12 DOI: 10.1136/ebmed-2017-110713
Mohammad Hassan Murad, Zhen Wang

Published research should be reported to evidence users with clarity and transparency that facilitate optimal appraisal and use of evidence and allow replication by other researchers. Guidelines for such reporting are available for several types of studies but not for meta-epidemiological methodology studies. Meta-epidemiological studies adopt a systematic review or meta-analysis approach to examine the impact of certain characteristics of clinical studies on the observed effect and provide empirical evidence for hypothesised associations. The unit of analysis in meta-epidemiological studies is a study, not a patient. The outcomes of meta-epidemiological studies are usually not clinical outcomes. In this guideline, we adapt items from the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) to fit the context of meta-epidemiological studies.

已发表的研究应以清晰和透明的方式向证据使用者报告,以促进对证据的最佳评价和使用,并允许其他研究人员复制。这类报告的指南适用于几种类型的研究,但不适用于元流行病学方法学研究。荟萃流行病学研究采用系统回顾或荟萃分析方法来检查临床研究的某些特征对观察到的效果的影响,并为假设的关联提供经验证据。元流行病学研究的分析单位是一项研究,而不是一个病人。元流行病学研究的结果通常不是临床结果。在本指南中,我们调整了系统评价和荟萃分析首选报告项目(PRISMA)中的项目,以适应荟萃流行病学研究的背景。
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引用次数: 216
Determining clinical decision thresholds for HIV-positive patients suspected of having tuberculosis. 确定怀疑患有结核病的艾滋病毒阳性患者的临床决策阈值。
Pub Date : 2017-08-01 Epub Date: 2017-07-17 DOI: 10.1136/ebmed-2017-110718
Tom Boyles, Isabella Locatelli, Nicolas Senn, Mark Ebell

Clinical decision thresholds may aid the evaluation of diagnostic tests but have rarely been determined for tuberculosis (TB). We presented clinicians with six web-based clinical scenarios, describing patients with HIV and possible TB at various sites and with a range of clinical stability. The probability of disease was varied randomly and clinicians asked to make treatment decisions; threshold curves and therapeutic thresholds were calculated. Test and treatment thresholds were calculated using Bayes theorem and the diagnostic accuracy of Xpert MTB/RIF. We received 165 replies to our survey. Therapeutic thresholds vary depending on the clinical stability and site of suspected disease. For inpatients, it ranges from 3.4% in unstable to 79.6% in stable patients. For TB meningitis, it ranges from 0% in unstable to 51.4% in stable patients and for pulmonary TB in outpatients it ranges from 29.1% in unstable to 74.5% in the stable patients. Test and treatment thresholds vary in a similar way with test thresholds ranging from 0 in unstable patients with suspected meningitis to 8.2% for stable inpatients. Treatment thresholds vary from 0 for unstable patients with suspected meningitis to 97% for stable inpatients. Therapeutic thresholds for TB can be determined by presenting clinicians with patient scenarios with random probabilities of disease and can be used to calculate test and treatment thresholds using Bayes theorem. Thresholds are lower when patients are more clinically unstable and when the implications of inappropriately withholding therapy are more serious. These results can be used to improve use and evaluation of diagnostic tests.

临床决策阈值可能有助于诊断测试的评估,但很少确定结核病(TB)。我们向临床医生展示了六个基于网络的临床场景,描述了不同地点的艾滋病毒和可能的结核病患者,并具有一系列临床稳定性。发病概率随机变化,临床医生被要求做出治疗决定;计算阈值曲线和治疗阈值。采用贝叶斯定理和Xpert MTB/RIF的诊断准确率计算检验和治疗阈值。我们收到了165份调查回复。治疗阈值取决于临床稳定性和疑似疾病的部位。对于住院患者,不稳定患者的比例为3.4%,稳定患者的比例为79.6%。对于结核性脑膜炎,不稳定患者的发病率从0%到稳定患者的51.4%不等,对于肺结核门诊患者,不稳定患者的发病率从29.1%到稳定患者的74.5%不等。检测阈值和治疗阈值也以类似的方式变化,检测阈值从不稳定的疑似脑膜炎患者的0到稳定的住院患者的8.2%不等。治疗阈值从不稳定的疑似脑膜炎患者的0到稳定的住院患者的97%不等。结核病的治疗阈值可通过向临床医生提供具有随机疾病概率的患者情景来确定,并可使用贝叶斯定理计算检验和治疗阈值。当患者在临床上更不稳定时,当不适当地停止治疗的影响更严重时,阈值较低。这些结果可用于改进诊断试验的使用和评价。
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引用次数: 10
Placebo might be superior to antipsychotics in management of delirium in the palliative care setting. 在姑息治疗中,安慰剂治疗谵妄可能优于抗精神病药物。
Pub Date : 2017-08-01 Epub Date: 2017-06-21 DOI: 10.1136/ebmed-2017-110723
Soenke Boettger, Josef Jenewein
Commentary on: Agar MR, Lawlor PG, Quinn S, et al . Efficacy of oral risperidone, haloperidol, or placebo for symptoms of delirium among patients in palliative care: a randomized clinical trial. JAMA Intern Med 2017;177:34–42.The need for controlled trials evaluating the efficacy of antipsychotics in the management of delirium has been recognised since the Practice Guidelines for the treatment of patients with delirium were introduced in 1999.1 Since then, only few relevant studies have been published. In contrast to the Practice Guidelines, which favoured psychopharmacological management, the National Institute for Health and Care Excellence Guidelines solely recommend psychopharmacological management for distress.2 To date, it has not yet been clearly defined what the distressing symptoms of delirium are. Considering this controversy and the necessity of further studies in this domain, the most beneficial approach for delirious patients remains unclear.3 4 In this multicentre, randomised clinical trial in the palliative care …
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引用次数: 4
Clinicians should assess the benefits and risks of using bezlotoxumab for reducing the risk of recurrent Clostridium difficile infection. 临床医生应评估使用bezlotoxumab降低艰难梭菌感染复发风险的获益和风险。
Pub Date : 2017-08-01 Epub Date: 2017-07-17 DOI: 10.1136/ebmed-2017-110722
Habiba Hassouna, Abhishek Deshpande
Commentry on: Wilcox MH, Gerding DN, Poxton IR, et al . Bezlotoxumab for Prevention of Recurrent Clostridium difficile Infection. N Engl J Med 2017;376:305–317.Clostridium difficile is an anaerobic gram-positive spore-forming bacillus that plays a major role in healthcare antibiotic-associated diarrhoea. A continued rise in antibiotic use, specifically, cephalosporins and fluoroquinolones, has been linked to the development of more resistant strains of this toxin-forming pathogen, triggering more recurrences and severe manifestations of the disease across USA and Europe.1 The high burden of recurrence and increased healthcare costs associated with C. difficile infection (CDI) have encouraged the development of new treatments to prevent recurrence including the use of pulsed/tapered oral vancomycin, fidaxomicin and faecal microbiota transplantation (FMT).2 Monoclonal antibodies for C. difficile therapy (MODIFY) trials I and II are two global phase 3 trials aimed at examining the efficacy and safety of a single dose (10 mg/kg) of human monoclonal antibodies actoxumab and bezlotoxumab against C. …
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引用次数: 0
Induction of labour at 37 weeks for suspected fetal macrosomia may reduce birth trauma. 怀疑胎儿巨大儿的37周引产可减少分娩创伤。
Pub Date : 2017-08-01 Epub Date: 2017-06-23 DOI: 10.1136/ebmed-2017-110693
Kate Walker, Jim Thornton
Citation:  Magro-Malosso ER, Saccone G, Chen M, et al . Induction of labour for suspected macrosomia at term in non-diabetic women: a systematic review and meta-analysis of randomised controlled trials. BJOG 2017;124:414-21.Mothers with big babies tend to have longer labours and more difficult births. They may require caesarean section, or instrumental vaginal delivery. They may also sustain perineal injury or more seriously the head may deliver and the shoulders get stuck, so-called shoulder dystocia. This severe complication may cause birth injury, including brachial plexus injury (2%–16%) which may be permanent and disabling. Finally, the baby may suffer bony fractures or birth asphyxia with risk of neurological damage or death. Obstetricians have wondered whether inducing labour early might make birth easier and reduce injury, …
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引用次数: 2
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Evidence-Based Medicine
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