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Effectiveness of assisted reproductive technology (ART). 辅助生殖技术(ART)的有效性。
Evan R Myers, Douglas C McCrory, Alyssa A Mills, Thomas M Price, Geeta K Swamy, Julierut Tantibhedhyangkul, Jennifer M Wu, David B Matchar

Objectives: We reviewed the evidence regarding the outcomes of interventions used in ovulation induction, superovulation, and in vitro fertilization (IVF) for the treatment of infertility. Short-term outcomes included pregnancy, live birth, multiple gestation, and complications. Long-term outcomes included pregnancy and post-pregnancy complications for both mothers and infants.

Data sources: MEDLINE and Cochrane Collaboration resources.

Review methods: We included studies published in English from January 2000 through January 2008. For short-term outcomes, we excluded non-randomized studies and studies where a pregnancy or live birth rate per subject could not be calculated. For long-term outcomes, we excluded studies with fewer than 100 subjects and those without a control group. Articles were abstracted for relevant details, and relative risks or odds ratios, with 95 percent confidence intervals, were calculated for outcomes of interest for each study.

Results: We identified 5294 abstracts and (for the three questions discussed in this draft report) reviewed 1210 full-text articles and included 478 articles for abstraction. Approximately 80 percent of the included studies were performed outside the United States. The majority of randomized trials were not designed to detect differences in pregnancy and live birth rates; reporting of delivery rates and obstetric outcomes was unusual. Most did not have sufficient power to detect clinically meaningful differences in live birth rates, and had still lower power to detect differences in less frequent outcomes such as multiple births and complications. Interventions for which there was sufficient evidence to demonstrate improved pregnancy or live birth rates included: (a) administration of clomiphene citrate in women with polycystic ovarian syndrome, (b) metformin plus clomiphene in women who fail to respond to clomiphene alone; (c) ultrasound-guided embryo transfer, and transfer on day 5 post-fertilization, in couples with a good prognosis; and (d) assisted hatching in couples with previous IVF failure. There was insufficient evidence regarding other interventions. Infertility itself is associated with most of the adverse longer-term outcomes. Consistently, infants born after infertility treatments are at risk for complications associated with abnormal implantation or placentation; the degree to which this is due to the underlying infertility, treatment, or both is unclear. Infertility, but not infertility treatment, is associated with an increased risk of breast and ovarian cancer.

Conclusions: Despite the large emotional and economic burden resulting from infertility, there is relatively little high-quality evidence to support the choice of specific interventions. Removing barriers to conducting appropriately designed studies should be a major policy goal.

目的:我们回顾了有关促排卵、超排卵和体外受精(IVF)治疗不孕症的干预结果的证据。短期结果包括妊娠、活产、多胎妊娠和并发症。长期结果包括母亲和婴儿的妊娠和妊娠后并发症。数据来源:MEDLINE和Cochrane协作资源。回顾方法:我们纳入了2000年1月至2008年1月间发表的英文研究。对于短期结果,我们排除了非随机研究和无法计算每个受试者的怀孕率或活产率的研究。对于长期结果,我们排除了少于100名受试者和没有对照组的研究。对文章进行相关细节的摘要,并对每项研究的相关结果计算相对风险或优势比,置信区间为95%。结果:我们确定了5294篇摘要,(针对本报告草稿中讨论的三个问题)审查了1210篇全文文章,并纳入了478篇文章进行摘要。大约80%的纳入研究是在美国以外进行的。大多数随机试验的设计并不是为了检测怀孕率和活产率的差异;报告分娩率和产科结果是不寻常的。大多数没有足够的能力来检测活产率的临床有意义的差异,并且在检测多胎和并发症等不常见结果的差异方面的能力更低。有充分证据证明妊娠率或活产率改善的干预措施包括:(a)多囊卵巢综合征妇女服用枸橼酸克罗米芬,(b)对单独服用克罗米芬无效的妇女服用二甲双胍加克罗米芬;(c)超声引导胚胎移植,对预后良好的夫妇在受精后第5天进行移植;(d)协助先前IVF失败的夫妇孵化。关于其他干预措施的证据不足。不孕症本身与大多数不良的长期结果有关。一贯地,不孕症治疗后出生的婴儿有与异常着床或胎盘相关的并发症的风险;这在多大程度上是由于潜在的不孕症,治疗,或两者兼而有之尚不清楚。不孕不育,而不是不孕不育治疗,与乳腺癌和卵巢癌的风险增加有关。结论:尽管不孕不育造成了巨大的情感和经济负担,但支持选择特定干预措施的高质量证据相对较少。消除进行适当设计的研究的障碍应该是一个主要的政策目标。
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引用次数: 0
Outcomes of maternal weight gain. 母亲体重增加的结果。
Meera Viswanathan, Anna Maria Siega-Riz, Merry K Moos, Andrea Deierlein, Sunni Mumford, Julie Knaack, Patricia Thieda, Linda J Lux, Kathleen N Lohr

Objectives: The RTI International-University of North Carolina at Chapel Hill Evidence-based Practice Center (RTI-UNC EPC) systematically reviewed evidence on outcomes of gestational weight gain and their confounders and effect modifiers, outcomes of weight gain within or outside the 1990 Institute of Medicine (IOM) guidelines, risks and benefits of weight gain recommendations, and anthropometric measures of weight gain.

Data sources: We searched MEDLINE Cochrane Collaboration resources, Cumulative Index to Nursing & Allied Health Literature, and Embase.

Review methods: We included studies published in English from 1990 through October 2007. We excluded studies with low sample size (based on study design: case series <100 subjects and cohorts <40 subjects).

Results: Overall, strong evidence supported an association between gestational weight gains and the following outcomes: preterm birth, total birthweight, low birthweight (<2,500 g), macrosomia, large-for-gestational-age (LGA) infants, and small-for-gestational-age (SGA) infants; moderate evidence supported an association for cesarean delivery and intermediate-term weight retention (3 months to 3 years postpartum). The studies reviewed provided strong evidence for the independent association of pregravid weight status and outcomes, moderate evidence for age and parity, and weak evidence for race. Regarding outcomes of weight gain within or outside 1990 IOM guidelines, moderate to strong evidence suggests an association between weight gain below IOM recommendations and preterm birth, low birthweight, SGA birthweights, and failure to initiate breastfeeding, and strong evidence for the association between weight gain above IOM recommendations and high birthweight, macrosomia, and LGA birthweights. Moderate evidence supports an association between weight gain above IOM guidelines and cesarean delivery and postpartum weight retention in the short, intermediate, and long term. Included research is inadequate for objective assessments of the range of harms and benefits of providing all women, irrespective of age, race or ethnicity, or pregravid body mass index (BMI), with the same recommendation for weight gain in pregnancy.

Conclusions: Gestational weight gain is associated with some infant and maternal outcomes. One weight gain recommendation for all women is not supported by the evidence identified in this review. To understand fully the impact of gestational weight gain on short- and long-term outcomes for women and their offspring will require that researchers use consistent definitions of weight gain during pregnancy, better address confounders in their analyses, improve study designs and statistical models, and conduct studies with longer followup.

目的:RTI国际-北卡罗来纳大学教堂山分校循证实践中心(RTI- unc EPC)系统地回顾了妊娠期体重增加的结果及其混杂因素和影响因素,体重增加的结果符合或不符合1990年医学研究所(IOM)指南,体重增加建议的风险和益处,以及体重增加的人体测量测量。数据来源:我们检索了MEDLINE Cochrane协作资源、护理与相关健康文献累积索引和Embase。回顾方法:我们纳入了从1990年到2007年10月用英文发表的研究。我们排除了低样本量的研究(基于研究设计:病例系列)结果:总体而言,强有力的证据支持妊娠期体重增加与以下结局之间的关联:早产、总出生体重、低出生体重(结论:妊娠期体重增加与一些婴儿和母亲的结局有关。本综述中发现的证据并不支持对所有女性增加体重的建议。为了充分了解孕期体重增加对妇女及其后代的短期和长期结果的影响,研究人员需要对孕期体重增加使用一致的定义,在分析中更好地解决混杂因素,改进研究设计和统计模型,并进行更长时间的随访研究。
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引用次数: 0
Diabetes education for children with type 1 diabetes mellitus and their families. 1型糖尿病儿童及其家庭的糖尿病教育。
Robert Couch, Mary Jetha, Donna M Dryden, Nicola Hooten, Yuanyuan Liang, Tamara Durec, Elizabeth Sumamo, Carol Spooner, Andrea Milne, Kate O'Gorman, Terry P Klassen

Objectives: To determine the effectiveness of diabetes education on metabolic control, diabetes-related hospitalizations, complications, and knowledge, quality of life and other psychosocial outcomes for children with type 1 diabetes and their families.

Data sources: A systematic and comprehensive literature review was conducted in 21 electronic databases of medical and health education literature to identify randomized controlled trials (RCTs) and observational studies evaluating the effectiveness of diabetes education.

Review methods: Study selection, quality assessment, and data extraction were conducted independently by several investigators in duplicate. A descriptive analysis is presented.

Results: From 12,756 citations, 80 studies were identified and included in the review (53 RCTs or CCTs, 27 observational studies). The methodological quality of studies was generally low. Most studies (35/52) that examined the effect of educational interventions on HbA1c found no evidence of increased effectiveness of the interventions over the education provided as part of standard care. Successful interventions were heterogeneous and included cognitive behavioral therapy, family therapy, skills training and general diabetes education. Most studies reported a positive effect on health service utilization (i.e., reduced use), although less than half were statistically significant. There was no clear evidence that educational interventions had an effect on short-term complications. The effect of educational interventions on diabetes knowledge was unclear with 12/30 studies reporting a significant improvement. Interventions which had varying effects on knowledge scores included diabetes camp, general diabetes education, and cognitive behavioral therapy. In the area of self management/regimen adherence, 10/21 studies reported improving this outcome significantly. Successful interventions included general diabetes education and cognitive behavioral therapy. Educational interventions were successful in improving various psychosocial outcomes. The results of two studies examining refinements to intensive therapy education suggest that educational interventions may enhance the effects of intensive diabetes management in reducing HbA1c. CONCLUSIONS Due to the heterogeneity of reported diabetes education interventions, outcome measures, and duration of followup, there is insufficient evidence to identify a particular intervention that is more effective than standard care to improve diabetes control or quality of life or to reduce short-term complications.

目的:确定糖尿病教育在1型糖尿病儿童及其家庭的代谢控制、糖尿病相关住院、并发症、知识、生活质量和其他社会心理结局方面的有效性。资料来源:对21个医学和健康教育文献电子数据库进行系统、全面的文献综述,以确定评估糖尿病教育有效性的随机对照试验(rct)和观察性研究。综述方法:研究选择、质量评估和数据提取由多位研究者独立进行,一式两份。提出了一种描述性分析。结果:从12756次引用中,80项研究被确定并纳入本综述(53项随机对照试验或随机对照试验,27项观察性研究)。研究的方法学质量普遍较低。大多数研究(35/52)检查了教育干预对HbA1c的影响,没有证据表明干预比作为标准治疗的一部分提供的教育更有效。成功的干预包括认知行为治疗、家庭治疗、技能培训和普通糖尿病教育。大多数研究报告了对保健服务利用的积极影响(即减少使用),尽管只有不到一半具有统计意义。没有明确的证据表明教育干预对短期并发症有影响。教育干预对糖尿病知识的影响尚不清楚,有12/30的研究报告有显著改善。对知识得分有不同影响的干预措施包括糖尿病训练营、糖尿病普通教育和认知行为治疗。在自我管理/方案依从性方面,10/21的研究报告显着改善了这一结果。成功的干预措施包括普通糖尿病教育和认知行为治疗。教育干预在改善各种社会心理结果方面取得了成功。两项关于强化治疗教育改进的研究结果表明,教育干预可能增强强化糖尿病管理在降低HbA1c方面的效果。结论:由于报道的糖尿病教育干预措施、结果测量和随访时间的异质性,没有足够的证据表明某一特定的干预措施在改善糖尿病控制或生活质量或减少短期并发症方面比标准护理更有效。
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引用次数: 0
Therapeutic management, delivery, and postpartum risk assessment and screening in gestational diabetes. 妊娠期糖尿病的治疗管理、分娩和产后风险评估和筛查。
Wanda K Nicholson, Lisa M Wilson, Catherine Takacs Witkop, Kesha Baptiste-Roberts, Wendy L Bennett, Shari Bolen, Bethany B Barone, Sherita Hill Golden, Tiffany L Gary, Donna M Neale, Eric B Bass

Objectives: We focused on four questions: What are the risks and benefits of an oral diabetes agent (i.e., glyburide), as compared to all types of insulin, for gestational diabetes? What is the evidence that elective labor induction, cesarean delivery, or timing of induction is associated with benefits or harm to the mother and neonate? What risk factors are associated with the development of type 2 diabetes after gestational diabetes? What are the performance characteristics of diagnostic tests for type 2 diabetes in women with gestational diabetes?

Data sources: We searched electronic databases for studies published through January 2007. Additional articles were identified by searching the table of contents of 13 journals for relevant citations from August 2006 to January 2007 and reviewing the references in eligible articles and selected review articles.

Review methods: Paired investigators reviewed abstracts and full articles. We included studies that were written in English, reported on human subjects, contained original data, and evaluated women with appropriately diagnosed gestational diabetes. Paired reviewers performed serial abstraction of data from each eligible study. Study quality was assessed independently by each reviewer.

Results: The search identified 45 relevant articles. The evidence indicated that: Maternal glucose levels do not differ substantially in those treated with insulin versus insulin analogues or oral agents. Average infant birth weight may be lower in mothers treated with insulin than with glyburide. Induction at 38 weeks may reduce the macrosomia rate, with no increase in cesarean delivery rates. Anthropometric measures, fasting blood glucose (FBG), and 2-hour glucose value are the strongest risk factors associated with development of type 2 diabetes. FBG had high specificity, but variable sensitivity, when compared to the 75-gm oral glucose tolerance test (OGTT) in the diagnosis of type 2 diabetes after delivery.

Conclusions: The evidence suggests that benefits and a low likelihood of harm are associated with the treatment of gestational diabetes with an oral diabetes agent or insulin. The effect of induction or elective cesarean on outcomes is unclear. The evidence is consistent that anthropometry identifies women at risk of developing subsequent type 2 diabetes; however, no evidence suggested the FBG out-performs the 75-gm OGTT in diagnosing type 2 diabetes after delivery.

目的:我们关注四个问题:与所有类型的胰岛素相比,口服糖尿病药物(即格列本脲)治疗妊娠糖尿病的风险和益处是什么?有什么证据表明择期引产、剖宫产或引产时机对母亲和新生儿有益或有害?妊娠期糖尿病后发生2型糖尿病的危险因素是什么?妊娠期糖尿病妇女2型糖尿病诊断试验的表现特点是什么?数据来源:我们检索了2007年1月之前发表的研究的电子数据库。通过检索13种期刊2006年8月至2007年1月的相关引文,并审查符合条件的文章和选定的综述文章中的参考文献,确定了其他文章。回顾方法:配对调查人员回顾摘要和全文。我们纳入了用英文撰写的、以人类受试者为研究对象的、包含原始数据的研究,并评估了诊断为妊娠糖尿病的妇女。配对审稿人从每个符合条件的研究中连续提取数据。研究质量由每位审稿人独立评估。结果:检索到45篇相关文章。证据表明:与胰岛素类似物或口服药物相比,接受胰岛素治疗的孕妇血糖水平没有显著差异。接受胰岛素治疗的母亲的婴儿平均出生体重可能低于格列本脲治疗的母亲。38周引产可降低巨大儿率,但不增加剖宫产率。人体测量、空腹血糖(FBG)和2小时血糖值是与2型糖尿病发展相关的最强危险因素。与75 gm口服葡萄糖耐量试验(OGTT)相比,FBG在诊断分娩后2型糖尿病方面具有高特异性,但敏感性不同。结论:有证据表明,口服糖尿病药物或胰岛素治疗妊娠期糖尿病的益处和低危害可能性相关。诱导或选择性剖宫产对结局的影响尚不清楚。有一致的证据表明,人体测量可以识别出有患2型糖尿病风险的女性;然而,没有证据表明FBG在诊断产后2型糖尿病方面优于75克OGTT。
{"title":"Therapeutic management, delivery, and postpartum risk assessment and screening in gestational diabetes.","authors":"Wanda K Nicholson,&nbsp;Lisa M Wilson,&nbsp;Catherine Takacs Witkop,&nbsp;Kesha Baptiste-Roberts,&nbsp;Wendy L Bennett,&nbsp;Shari Bolen,&nbsp;Bethany B Barone,&nbsp;Sherita Hill Golden,&nbsp;Tiffany L Gary,&nbsp;Donna M Neale,&nbsp;Eric B Bass","doi":"","DOIUrl":"","url":null,"abstract":"<p><strong>Objectives: </strong>We focused on four questions: What are the risks and benefits of an oral diabetes agent (i.e., glyburide), as compared to all types of insulin, for gestational diabetes? What is the evidence that elective labor induction, cesarean delivery, or timing of induction is associated with benefits or harm to the mother and neonate? What risk factors are associated with the development of type 2 diabetes after gestational diabetes? What are the performance characteristics of diagnostic tests for type 2 diabetes in women with gestational diabetes?</p><p><strong>Data sources: </strong>We searched electronic databases for studies published through January 2007. Additional articles were identified by searching the table of contents of 13 journals for relevant citations from August 2006 to January 2007 and reviewing the references in eligible articles and selected review articles.</p><p><strong>Review methods: </strong>Paired investigators reviewed abstracts and full articles. We included studies that were written in English, reported on human subjects, contained original data, and evaluated women with appropriately diagnosed gestational diabetes. Paired reviewers performed serial abstraction of data from each eligible study. Study quality was assessed independently by each reviewer.</p><p><strong>Results: </strong>The search identified 45 relevant articles. The evidence indicated that: Maternal glucose levels do not differ substantially in those treated with insulin versus insulin analogues or oral agents. Average infant birth weight may be lower in mothers treated with insulin than with glyburide. Induction at 38 weeks may reduce the macrosomia rate, with no increase in cesarean delivery rates. Anthropometric measures, fasting blood glucose (FBG), and 2-hour glucose value are the strongest risk factors associated with development of type 2 diabetes. FBG had high specificity, but variable sensitivity, when compared to the 75-gm oral glucose tolerance test (OGTT) in the diagnosis of type 2 diabetes after delivery.</p><p><strong>Conclusions: </strong>The evidence suggests that benefits and a low likelihood of harm are associated with the treatment of gestational diabetes with an oral diabetes agent or insulin. The effect of induction or elective cesarean on outcomes is unclear. The evidence is consistent that anthropometry identifies women at risk of developing subsequent type 2 diabetes; however, no evidence suggested the FBG out-performs the 75-gm OGTT in diagnosing type 2 diabetes after delivery.</p>","PeriodicalId":72991,"journal":{"name":"Evidence report/technology assessment","volume":" 162","pages":"1-96"},"PeriodicalIF":0.0,"publicationDate":"2008-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4781072/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"27421984","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Hydroxyurea for the treatment of sickle cell disease. 羟基脲治疗镰状细胞病。
Jodi B Segal, John J Strouse, Mary Catherine Beach, Carlton Haywood, Catherine Witkop, Haeseong Park, Renee F Wilson, Eric B Bass, Sophie Lanzkron

Objectives: To synthesize the published literature on the efficacy, effectiveness, and toxicity of hydroxyurea (HU) when used for treatment of sickle cell disease (SCD); and to review the evidence regarding barriers to its use.

Data sources: Articles cited in MEDLlNE, EMBASE, TOXLine, and CINAHL through June 30, 2007.

Review methods: Paired reviewers reviewed each title, abstract, and article to assess eligibility. They abstracted data sequentially and then independently graded the evidence.

Results: In one small, randomized trial of HU in children with SCD; the yearly hospitalization rate was lower with HU than placebo (1.1 versus 2.8, p=0.002). The absolute increase in fetal hemoglobin (Hb F%) was 10.7 percent. Twenty observational studies of HU in children reported similar increases in Hb F%, while hemoglobin concentration increased by roughly 1 g/dl. One large randomized trial tested the efficacy of HU in adults with SCD and found that after 2 years of treatment, Hb F% increased by 3.2 percent and hemoglobin increased by 0.6 g/dl, The median number of painful crises was 44 percent (p<0.001) lower among patients treated with HU. The 12 observational studies of HU enrolling adults with SCD supported these findings. Panelists from the Center for the Evaluation of Risks to Human Reproduction reviewed the literature for potential toxicities of HU. They concluded that HU does not cause a growth delay in children 5-15 years old. There were no data on the effects on subsequent generations following exposure of developing germ cells to HU in utero. Some evidence supported impaired spermatogenesis with use of HU. Although we identified six patients taking HU who developed leukemia, the evidence did not support causality. Similarly, the evidence suggested no association between HU and leg ulcers in patients with SCD, although there was in patients with other illnesses. The literature supported neutropenia, skin rashes and nail changes associated with use of HU, but was sparse regarding skin neoplasms or other secondary malignancies in SCD. Only two studies investigated barriers to use of HU. Perceived efficacy and perceived safety of HU had the largest influence on patients' (or parents' ) choice to use HU. Providers reported barriers to be patient concerns about side effects; and their own concerns about HU in older patients, patient compliance, lack of contraception, side effects and carcinogenic potential, doubts about effectiveness, and concern about costs.

Conclusions: HU is efficacious in children and adults with SCD; with an increase in Hb F%, and reduction in hospitalizations and pain crises. However, few studies have measured the effectiveness of HU for SCD in usual practice. The paucity of long-term studies limits conclusions about toxicities and about mortality. Future studies of interventions to overcome the barriers to use of HU i

目的:对羟基脲(HU)治疗镰状细胞病(SCD)的疗效、有效性和毒性进行文献综述;并审查有关其使用障碍的证据。数据来源:2007年6月30日在MEDLlNE、EMBASE、TOXLine和CINAHL中引用的文章。评审方法:配对评审人员对每个标题、摘要和文章进行评审,以评估合格性。他们按顺序提取数据,然后独立地对证据进行分级。结果:在一项SCD患儿HU的小型随机试验中;HU组的年住院率低于安慰剂组(1.1比2.8,p=0.002)。胎儿血红蛋白(Hb F%)绝对增加10.7%。20项儿童HU的观察性研究报告了类似的Hb F%的增加,而血红蛋白浓度增加了大约1 g/dl。一项大型随机试验测试了HU对成人SCD的疗效,发现治疗2年后,Hb F%增加3.2%,血红蛋白增加0.6 g/dl,疼痛危像的中位数为44%(结论:HU对儿童和成人SCD有效;Hb F%的增加,住院和疼痛危机的减少。然而,在常规实践中,很少有研究测量HU对SCD的有效性。长期研究的缺乏限制了关于毒性和死亡率的结论。未来有必要研究干预措施,以克服SCD患者使用HU的障碍。
{"title":"Hydroxyurea for the treatment of sickle cell disease.","authors":"Jodi B Segal,&nbsp;John J Strouse,&nbsp;Mary Catherine Beach,&nbsp;Carlton Haywood,&nbsp;Catherine Witkop,&nbsp;Haeseong Park,&nbsp;Renee F Wilson,&nbsp;Eric B Bass,&nbsp;Sophie Lanzkron","doi":"","DOIUrl":"","url":null,"abstract":"<p><strong>Objectives: </strong>To synthesize the published literature on the efficacy, effectiveness, and toxicity of hydroxyurea (HU) when used for treatment of sickle cell disease (SCD); and to review the evidence regarding barriers to its use.</p><p><strong>Data sources: </strong>Articles cited in MEDLlNE, EMBASE, TOXLine, and CINAHL through June 30, 2007.</p><p><strong>Review methods: </strong>Paired reviewers reviewed each title, abstract, and article to assess eligibility. They abstracted data sequentially and then independently graded the evidence.</p><p><strong>Results: </strong>In one small, randomized trial of HU in children with SCD; the yearly hospitalization rate was lower with HU than placebo (1.1 versus 2.8, p=0.002). The absolute increase in fetal hemoglobin (Hb F%) was 10.7 percent. Twenty observational studies of HU in children reported similar increases in Hb F%, while hemoglobin concentration increased by roughly 1 g/dl. One large randomized trial tested the efficacy of HU in adults with SCD and found that after 2 years of treatment, Hb F% increased by 3.2 percent and hemoglobin increased by 0.6 g/dl, The median number of painful crises was 44 percent (p<0.001) lower among patients treated with HU. The 12 observational studies of HU enrolling adults with SCD supported these findings. Panelists from the Center for the Evaluation of Risks to Human Reproduction reviewed the literature for potential toxicities of HU. They concluded that HU does not cause a growth delay in children 5-15 years old. There were no data on the effects on subsequent generations following exposure of developing germ cells to HU in utero. Some evidence supported impaired spermatogenesis with use of HU. Although we identified six patients taking HU who developed leukemia, the evidence did not support causality. Similarly, the evidence suggested no association between HU and leg ulcers in patients with SCD, although there was in patients with other illnesses. The literature supported neutropenia, skin rashes and nail changes associated with use of HU, but was sparse regarding skin neoplasms or other secondary malignancies in SCD. Only two studies investigated barriers to use of HU. Perceived efficacy and perceived safety of HU had the largest influence on patients' (or parents' ) choice to use HU. Providers reported barriers to be patient concerns about side effects; and their own concerns about HU in older patients, patient compliance, lack of contraception, side effects and carcinogenic potential, doubts about effectiveness, and concern about costs.</p><p><strong>Conclusions: </strong>HU is efficacious in children and adults with SCD; with an increase in Hb F%, and reduction in hospitalizations and pain crises. However, few studies have measured the effectiveness of HU for SCD in usual practice. The paucity of long-term studies limits conclusions about toxicities and about mortality. Future studies of interventions to overcome the barriers to use of HU i","PeriodicalId":72991,"journal":{"name":"Evidence report/technology assessment","volume":" 165","pages":"1-95"},"PeriodicalIF":0.0,"publicationDate":"2008-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4781604/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"27421988","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Utility of monitoring mycophenolic acid in solid organ transplant patients. 实体器官移植患者霉酚酸监测的应用。
Mark Oremus, Johannes Zeidler, Mary H H Ensom, Mina Matsuda-Abedini, Cynthia Balion, Lynda Booker, Carolyn Archer, Parminder Raina

Objectives: To investigate whether monitoring concentrations of mycophenolic acid (MPA) in the serum or plasma of persons who receive a solid organ transplant will result in a lower incidence of transplant rejections and adverse events versus no monitoring of MPA. To investigate whether the incidence of rejection or adverse events differs according to MPA dose or frequency, type of MPA, the form of MPA monitored, the method of MPA monitoring, or sample characteristics. To assess whether monitoring is cost-effective versus no monitoring.

Data sources: The following databases were searched from their dates of inception (in brackets) until October 2007: MEDLINE (1966); BIOSIS Previews (1976); EMBASE (1980); Cochrane Database of Systematic Reviews (1995); and Cochrane Central Register of Controlled Trials (1995).

Review methods: Studies identified from the data sources went through two levels of screening (i.e., title and abstract, full text) and the ones that passed were abstracted. Criteria for abstraction included publication in the English language, study design (i.e., randomized controlled trial [RCT], observational study with comparison group, case series), and patient receipt of allograft solid organ transplant. Additionally, any form of MPA had to be measured at least once in the plasma or serum using any method of measurement (e.g., AUC0-12, C0). Furthermore, these measures had to be linked to a health outcome (e.g., transplant rejection). Certain biomarkers (e.g., serum creatinine, glomular filtration rate) and all adverse events were also considered health outcomes.

Results: The published evidence on MPA monitoring is inconclusive. Direct, head-to-head comparison of monitoring versus no monitoring is limited to one RCT in adult, kidney transplant patients. Inferences about monitoring can be made from some observational studies, although the evidence is equivocal for MPA dose and dose frequency, nonexistent for type of MPA, inconclusive for form of MPA monitored or method of monitoring, and nonexistent for cost-effectiveness. Some studies suggest gender and concomitant use of calcineurin inhibitors will affect pharmacokinetic parameters, but the impact of these findings has not been assessed in relation to monitoring versus no monitoring.

Conclusions: The state of knowledge about therapeutic drug monitoring of MPA in solid organ transplants is still in its infancy. Until there is more evidence on the utility of routine MPA monitoring in solid organ transplant recipients, patients, clinicians, and other stakeholders (e.g., public and private insurers) will have to decide on a case by case basis whether the possible but uncertain benefits are worth the extra time and expense of monitoring.

目的:研究监测接受实体器官移植患者血清或血浆中霉酚酸(MPA)的浓度与不监测MPA相比,是否会降低移植排斥反应和不良事件的发生率。探讨不良反应或排斥反应的发生率是否因MPA剂量或频率、MPA类型、MPA监测形式、MPA监测方法或样本特征的不同而不同。评估监测与不监测是否具有成本效益。数据来源:从数据库建立日期(括号内)至2007年10月检索以下数据库:MEDLINE (1966);BIOSIS预览(1976年);EMBASE (1980);Cochrane系统评价数据库(1995);和Cochrane中央对照试验登记册(1995)。审查方法:从数据源中确定的研究经过两个层次的筛选(即标题和摘要、全文),通过筛选的研究进行摘要。摘要标准包括英文出版物、研究设计(即随机对照试验[RCT]、对照组观察性研究、病例系列)和患者接受同种异体实体器官移植。此外,任何形式的MPA必须使用任何测量方法(例如AUC0-12, C0)在血浆或血清中至少测量一次。此外,这些措施必须与健康结果(例如,移植排斥反应)联系起来。某些生物标志物(如血清肌酐、肾小球滤过率)和所有不良事件也被视为健康结果。结果:已发表的MPA监测证据尚无定论。监测与不监测的直接对比仅限于一项成人肾移植患者的随机对照试验。从一些观察性研究中可以得出关于监测的推断,尽管MPA剂量和剂量频率的证据是模棱两可的,MPA类型的证据是不存在的,MPA监测的形式或监测方法的证据是不确定的,并且没有成本效益的证据。一些研究表明,性别和钙调磷酸酶抑制剂的同时使用会影响药代动力学参数,但这些研究结果的影响尚未评估与监测和不监测相关的影响。结论:我国对实体器官移植中MPA治疗药物监测的认识尚处于起步阶段。在有更多证据表明常规MPA监测在实体器官移植受者中的效用之前,患者、临床医生和其他利益相关者(例如,公共和私人保险公司)将不得不根据具体情况决定是否值得花费额外的时间和费用进行监测,这些可能但不确定的益处是否值得。
{"title":"Utility of monitoring mycophenolic acid in solid organ transplant patients.","authors":"Mark Oremus,&nbsp;Johannes Zeidler,&nbsp;Mary H H Ensom,&nbsp;Mina Matsuda-Abedini,&nbsp;Cynthia Balion,&nbsp;Lynda Booker,&nbsp;Carolyn Archer,&nbsp;Parminder Raina","doi":"","DOIUrl":"","url":null,"abstract":"<p><strong>Objectives: </strong>To investigate whether monitoring concentrations of mycophenolic acid (MPA) in the serum or plasma of persons who receive a solid organ transplant will result in a lower incidence of transplant rejections and adverse events versus no monitoring of MPA. To investigate whether the incidence of rejection or adverse events differs according to MPA dose or frequency, type of MPA, the form of MPA monitored, the method of MPA monitoring, or sample characteristics. To assess whether monitoring is cost-effective versus no monitoring.</p><p><strong>Data sources: </strong>The following databases were searched from their dates of inception (in brackets) until October 2007: MEDLINE (1966); BIOSIS Previews (1976); EMBASE (1980); Cochrane Database of Systematic Reviews (1995); and Cochrane Central Register of Controlled Trials (1995).</p><p><strong>Review methods: </strong>Studies identified from the data sources went through two levels of screening (i.e., title and abstract, full text) and the ones that passed were abstracted. Criteria for abstraction included publication in the English language, study design (i.e., randomized controlled trial [RCT], observational study with comparison group, case series), and patient receipt of allograft solid organ transplant. Additionally, any form of MPA had to be measured at least once in the plasma or serum using any method of measurement (e.g., AUC0-12, C0). Furthermore, these measures had to be linked to a health outcome (e.g., transplant rejection). Certain biomarkers (e.g., serum creatinine, glomular filtration rate) and all adverse events were also considered health outcomes.</p><p><strong>Results: </strong>The published evidence on MPA monitoring is inconclusive. Direct, head-to-head comparison of monitoring versus no monitoring is limited to one RCT in adult, kidney transplant patients. Inferences about monitoring can be made from some observational studies, although the evidence is equivocal for MPA dose and dose frequency, nonexistent for type of MPA, inconclusive for form of MPA monitored or method of monitoring, and nonexistent for cost-effectiveness. Some studies suggest gender and concomitant use of calcineurin inhibitors will affect pharmacokinetic parameters, but the impact of these findings has not been assessed in relation to monitoring versus no monitoring.</p><p><strong>Conclusions: </strong>The state of knowledge about therapeutic drug monitoring of MPA in solid organ transplants is still in its infancy. Until there is more evidence on the utility of routine MPA monitoring in solid organ transplant recipients, patients, clinicians, and other stakeholders (e.g., public and private insurers) will have to decide on a case by case basis whether the possible but uncertain benefits are worth the extra time and expense of monitoring.</p>","PeriodicalId":72991,"journal":{"name":"Evidence report/technology assessment","volume":" 164","pages":"1-131"},"PeriodicalIF":0.0,"publicationDate":"2008-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4780884/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"27421989","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Carbohydrate and lipid disorders and relevant considerations in persons with spinal cord injury. 脊髓损伤患者的碳水化合物和脂质紊乱及相关考虑。
Timothy J Wilt, Kathleen F Carlson, Gary D Goldish, Roderick MacDonald, Catherine Niewoehner, Indulis Rutks, Tatyana Shamliyan, James Tacklind, Brent C Taylor, Robert L Kane

Objectives: To assess the prevalence of carbohydrate and lipid disorders in adults with chronic spinal cord injury and evaluate their risk contribution to cardiovascular diseases and the potential impact of exercise and pharmacologic and dietary therapies to alter these disorders and reduce cardiovascular disease risk.

Data sources: MEDLINE (PubMed), Cochrane Database and Web sites of the American Spinal Injury Association, American Paraplegia Society, Paralyzed Veterans of America, Consortium of Spinal Cord Medicine, and WorldCat through August 2007.

Review methods: English language observational studies addressing prevalence of carbohydrate and lipid disorders were included if they evaluated at least 100 adults with chronic spinal cord injury or a total of 100 subjects if using a control group. Epidemiologic investigations of more than 50 adults with spinal cord injury that were published in English after 1990 and reported cardiovascular morbidity and mortality were abstracted. Intervention studies from 1996-2007 were included regardless of design or size if they assessed exercise, diet, or pharmacologic therapies and reported carbohydrate, lipid, or cardiovascular outcomes.

Results: The quality of evidence regarding the prevalence, impact, and outcomes of carbohydrate and lipid disorders in adults with chronic spinal cord injuries is weak. Evidence is limited by relatively few studies, small sample size, lack of appropriate control groups, failure to adjust for known confounding variables, and variation in reported outcomes. However, the existing evidence does not indicate that adults with spinal cord injuries are at markedly greater risk for carbohydrate and lipid disorders or subsequent cardiovascular morbidity and mortality than able-bodied adults. Body mass index is not reliable for assessing body composition, especially percent body fat, in adults with spinal cord injury. There are no high quality studies evaluating the impact of exercise, diet, or pharmacologic therapies on these disorders.

Conclusions: The available evidence does not support incorporating SCI status as an independent variable to assess risk of cardiovascular morbidity and mortality or to alter diagnostic/treatment thresholds compared to able-bodied adults. Furthermore, individuals with SCI may have unique physiologic differences compared to able-bodied individuals. As a result, it is uncertain that findings from studies conducted in able-bodied adults evaluating efficacy and harms of interventions to improve carbohydrate, lipid disorders, and subsequent CVD can be extrapolated to individuals with SCI. The role of exercise in individuals with spinal cord injuries represents a unique challenge and requires further exploration into the benefits, harms, and resource implications of broad-based spinal cord injury exercise programs.

目的:评估慢性脊髓损伤成人中碳水化合物和脂质紊乱的患病率,评估其对心血管疾病的风险贡献,以及运动、药物和饮食治疗对改变这些紊乱和降低心血管疾病风险的潜在影响。数据来源:截至2007年8月,MEDLINE (PubMed)、Cochrane数据库、美国脊髓损伤协会、美国截瘫协会、美国瘫痪退伍军人协会、脊髓医学联合会和WorldCat的网站。回顾方法:针对碳水化合物和脂质紊乱患病率的英语观察性研究,如果它们评估了至少100名慢性脊髓损伤的成年人,或者如果使用对照组,则总共评估了100名受试者。本文对1990年以后发表的50余例成人脊髓损伤的流行病学调查资料进行了总结,并对心血管疾病的发病率和死亡率进行了分析。1996-2007年的干预研究不论设计或大小,只要评估了运动、饮食或药物治疗,并报告了碳水化合物、脂质或心血管结果,就纳入研究。结果:关于慢性脊髓损伤成人中碳水化合物和脂质紊乱的患病率、影响和结局的证据质量较弱。由于研究相对较少,样本量小,缺乏适当的对照组,未能调整已知的混杂变量,以及报告结果的变化,证据受到限制。然而,现有的证据并不表明脊髓损伤的成年人发生碳水化合物和脂质紊乱或随后的心血管疾病和死亡的风险明显高于健全的成年人。在脊髓损伤的成年人中,体重指数对于评估身体成分,尤其是体脂百分比是不可靠的。目前还没有高质量的研究评估运动、饮食或药物治疗对这些疾病的影响。结论:现有证据不支持将脊髓损伤状态作为一个独立变量来评估心血管发病率和死亡率的风险,或与健全成人相比改变诊断/治疗阈值。此外,与健全个体相比,脊髓损伤个体可能具有独特的生理差异。因此,在健全成人中进行的评估干预措施改善碳水化合物、脂质紊乱和随后的CVD的疗效和危害的研究结果能否外推到脊髓损伤患者身上还不确定。运动在脊髓损伤患者中的作用是一个独特的挑战,需要进一步探索广泛的脊髓损伤运动项目的益处、危害和资源含义。
{"title":"Carbohydrate and lipid disorders and relevant considerations in persons with spinal cord injury.","authors":"Timothy J Wilt,&nbsp;Kathleen F Carlson,&nbsp;Gary D Goldish,&nbsp;Roderick MacDonald,&nbsp;Catherine Niewoehner,&nbsp;Indulis Rutks,&nbsp;Tatyana Shamliyan,&nbsp;James Tacklind,&nbsp;Brent C Taylor,&nbsp;Robert L Kane","doi":"","DOIUrl":"","url":null,"abstract":"<p><strong>Objectives: </strong>To assess the prevalence of carbohydrate and lipid disorders in adults with chronic spinal cord injury and evaluate their risk contribution to cardiovascular diseases and the potential impact of exercise and pharmacologic and dietary therapies to alter these disorders and reduce cardiovascular disease risk.</p><p><strong>Data sources: </strong>MEDLINE (PubMed), Cochrane Database and Web sites of the American Spinal Injury Association, American Paraplegia Society, Paralyzed Veterans of America, Consortium of Spinal Cord Medicine, and WorldCat through August 2007.</p><p><strong>Review methods: </strong>English language observational studies addressing prevalence of carbohydrate and lipid disorders were included if they evaluated at least 100 adults with chronic spinal cord injury or a total of 100 subjects if using a control group. Epidemiologic investigations of more than 50 adults with spinal cord injury that were published in English after 1990 and reported cardiovascular morbidity and mortality were abstracted. Intervention studies from 1996-2007 were included regardless of design or size if they assessed exercise, diet, or pharmacologic therapies and reported carbohydrate, lipid, or cardiovascular outcomes.</p><p><strong>Results: </strong>The quality of evidence regarding the prevalence, impact, and outcomes of carbohydrate and lipid disorders in adults with chronic spinal cord injuries is weak. Evidence is limited by relatively few studies, small sample size, lack of appropriate control groups, failure to adjust for known confounding variables, and variation in reported outcomes. However, the existing evidence does not indicate that adults with spinal cord injuries are at markedly greater risk for carbohydrate and lipid disorders or subsequent cardiovascular morbidity and mortality than able-bodied adults. Body mass index is not reliable for assessing body composition, especially percent body fat, in adults with spinal cord injury. There are no high quality studies evaluating the impact of exercise, diet, or pharmacologic therapies on these disorders.</p><p><strong>Conclusions: </strong>The available evidence does not support incorporating SCI status as an independent variable to assess risk of cardiovascular morbidity and mortality or to alter diagnostic/treatment thresholds compared to able-bodied adults. Furthermore, individuals with SCI may have unique physiologic differences compared to able-bodied individuals. As a result, it is uncertain that findings from studies conducted in able-bodied adults evaluating efficacy and harms of interventions to improve carbohydrate, lipid disorders, and subsequent CVD can be extrapolated to individuals with SCI. The role of exercise in individuals with spinal cord injuries represents a unique challenge and requires further exploration into the benefits, harms, and resource implications of broad-based spinal cord injury exercise programs.</p>","PeriodicalId":72991,"journal":{"name":"Evidence report/technology assessment","volume":" 163","pages":"1-95"},"PeriodicalIF":0.0,"publicationDate":"2008-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4781490/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"27421990","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
引用次数: 0
Prevention of urinary and fecal incontinence in adults. 成人尿便失禁的预防。
Tatyana Shamliyan, Jean Wyman, Donna Z Bliss, Robert L Kane, Timothy J Wilt

Objectives: To assess the prevalence of and risk factors for urinary (UI) and fecal (FI) incontinence in adults in long-term care (LTC) settings and in the community, the effectiveness of diagnostic methods to identify adults at risk and patients with incontinence, and to review the effectiveness of clinical interventions to reduce the risk of incontinence.

Data sources: MEDLINE (PubMed), CINAHL, and Cochrane Databases.

Review methods: Observational studies were reviewed to examine the prevalence and incidence of UI and FI and the association with risk factors. The effects of treatments on patient outcomes were analyzed from randomized controlled and multicenter clinical trials. The diagnostic values of the tests were compared from the original epidemiologic studies of different designs. Of the 6,097 articles identified, 1,077 articles were eligible for analysis.

Results: The prevalence of UI, FI, and combined incontinence increased with age and functional dependency. Cognitive impairment, limitations in daily activities, and prolonged institutionalization in nursing homes were associated with a higher risk of incontinence. Stroke, diabetes, obesity, poor general health, and comorbidities were associated with UI and FI in community dwelling adults. Parity, anal trauma, and vaginal prolapse in women and urological surgery and radiation for prostate cancer in men are risk factors for UI and FI. Intensive individualized management and rehabilitation programs improved continence status in nursing home residents and adults after stroke. Self-administered behavioral interventions including pelvic floor muscle training with biofeedback and bladder training resolved UI in incontinent women. Electrical stimulation and sacral neuromodulation improved urge UI, but improvement for FI was inconsistent. Tension-free vaginal tape procedures and modified surgical techniques for prolapse to support the bladder neck resolved stress UI in the majority of treated women. Behavioral treatments of FI resulted in small improvements in severity and quality of life related to incontinence. The effects on FI of surgical techniques for hemorrhoids, rectal prolapse, rectal cancer, and anal fissures are not consistent across studies. Surgical interventions in patients with ulcerative colitis resulted in the same rates of fecal continence when compared to each other. The few clinical interventions to treat FI that were tested in well-designed trials had no clear evidence of better effects of the compared treatments. Instrumental outcomes to evaluate the effectiveness of treatments did not correlate with patient outcomes. Epidemiologic surveys to detect persons at risk and patients with undiagnosed UI have the same diagnostic value and less cost compared to professional examinations and diagnostic tests. Self-reported questionnaires and scales have unsatisfactory validity to diagnose FI.

目的:评估长期护理(LTC)和社区成人尿失禁(UI)和粪失禁(FI)的患病率和危险因素,诊断方法识别有尿失禁风险的成人和尿失禁患者的有效性,并回顾临床干预措施降低尿失禁风险的有效性。数据来源:MEDLINE (PubMed)、CINAHL和Cochrane数据库。回顾方法:回顾观察性研究,以检查UI和FI的患病率和发病率及其与危险因素的关系。从随机对照和多中心临床试验中分析治疗对患者预后的影响。比较了不同设计的原始流行病学研究的诊断价值。在鉴定的6097篇文章中,有1077篇文章符合分析条件。结果:尿失禁、尿失禁和合并尿失禁的患病率随着年龄和功能依赖的增加而增加。认知障碍、日常活动限制和长期住在养老院与尿失禁的高风险相关。在社区居住的成年人中,中风、糖尿病、肥胖、一般健康状况不佳和合并症与UI和FI相关。女性的胎次、肛门创伤和阴道脱垂以及男性的泌尿外科手术和前列腺癌放疗是UI和FI的危险因素。强化的个体化管理和康复计划改善了养老院居民和成人中风后的自理状况。自我管理行为干预包括骨盆底肌肉训练与生物反馈和膀胱训练解决尿失禁妇女尿失禁。电刺激和骶神经调节可改善急迫性UI,但对FI的改善不一致。无张力阴道胶带手术和改良手术技术脱垂,以支持膀胱颈部解决压力性尿失禁在大多数接受治疗的妇女。FI的行为治疗导致与尿失禁相关的严重程度和生活质量的小幅改善。痔疮、直肠脱垂、直肠癌和肛裂手术技术对FI的影响在各研究中并不一致。溃疡性结肠炎患者的手术干预导致相同的大便失禁率,彼此比较。在精心设计的试验中,少数治疗FI的临床干预措施没有明确的证据表明比较治疗的效果更好。评估治疗效果的工具结果与患者结果无关。与专业检查和诊断测试相比,用于检测高危人群和未确诊的尿失尿患者的流行病学调查具有相同的诊断价值,而且费用更低。自我报告的问卷和量表诊断FI的效度不理想。结论:流行病学调查是一种经济有效的方法,可用于估计具有全国代表性的大型人群中尿失禁的患病率。常规临床评估应包括对尿失禁的危险因素、症状和体征的评估。孕妇或更年期妇女、阴道脱垂的妇女、接受过前列腺疾病治疗的男性、直肠脱垂的患者、体弱的老年人和养老院的居民都是高危人群。个性化管理方案可以改善LTC设施的自理能力,但难以维持。定期监测和记录与实施的失禁服务有关的失禁状况应成为养老院的护理质量指标。骨盆底肌肉训练与生物反馈可以解决尿失禁和提高生活质量。手术是治疗女性应激性尿失禁的有效方法。男性尿失禁和成人FI的临床干预措施需要进一步研究。提供了一份研究建议清单。
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引用次数: 0
Impact of gene expression profiling tests on breast cancer outcomes. 基因表达谱测试对乳腺癌预后的影响
Luigi Marchionni, Renee F Wilson, Spyridon S Marinopoulos, Antonio C Wolff, Giovanni Parmigiani, Eric B Bass, Steven N Goodman

Objectives: To assess the evidence that three marketed gene expression-based assays improve prognostic accuracy, treatment choice, and health outcomes in women diagnosed with early stage breast cancer.

Review methods: We evaluated the evidence for three gene expression assays on the market; Oncotype DX, MammaPrint and the Breast Cancer Profiling (BCP or H/I ratio) test, and for gene expression signatures underlying the assays. We sought evidence on: analytic performance of tests, clinical validity (i.e., prognostic accuracy and discrimination), clinical utility (i.e., prediction of treatment benefit), harms, impact on clinical decision making and health care costs.

Results: Few papers were found on the analytic validity of the Oncotype DX and MammaPrint tests, but these showed reasonable within-laboratory replicability. Pre-analytic issues related to sample storage and preparation may play a larger role than within-laboratory variation. For clinical validity, studies differed according to whether they examined the actual test that is currently being offered to patients or the underlying gene signature. Almost all of the Oncotype DX evidence was for the marketed test, the strongest validation study being from one arm of a randomized controlled trial (NSABP-14) with a clinically homogeneous population. This study showed that the test, added in a clinically meaningful manner to standard prognostic indices. The MammaPrint signature and test itself was examined in studies with clinically heterogeneous populations (e.g., mix of ER positivity and tamoxifen treatment) and showed a clinically relevant separation of patients into risk categories, but it was not clear exactly how many predictions would be shifted across decision thresholds if this were used in combination with traditional indices. The BCP test itself was examined in one study, and the signature was tested in a variety of formulations in several studies. One randomized controlled trial provided high quality retrospective evidence of the clinical utility of Oncotype DX to predict chemotherapy treatment benefit, but evidence for clinical utility was not found for MammaPrint or the H/I ratio. Three decision analyses examined the cost-effectiveness of breast cancer gene expression assays, and overall were inconclusive.

Conclusions: Oncotype DX is furthest along the validation pathway, with strong retrospective evidence that it predicts distant spread and chemotherapy benefit to a clinically relevant extent over standard predictors, in a well-defined clinical subgroup with clear treatment implications. The evidence for clinical implications of using MammaPrint was not as clear as with Oncotype DX, and the ability to predict chemotherapy benefit does not yet exist. The H/I ratio test requires further validation. For all tests, the relationship of predicted to observed risk in different populations still needs

目的:评估三种上市的基于基因表达的检测方法改善早期乳腺癌患者预后准确性、治疗选择和健康结局的证据。回顾方法:我们评估了市场上三种基因表达检测的证据;Oncotype DX、MammaPrint和乳腺癌谱(BCP或H/I比值)测试,以及这些测试背后的基因表达特征。我们寻求以下方面的证据:测试的分析性能、临床效度(即预测的准确性和辨别性)、临床效用(即预测治疗获益)、危害、对临床决策和医疗保健成本的影响。结果:很少有论文发现Oncotype DX和MammaPrint测试的分析有效性,但这些都显示了合理的实验室内可重复性。与样品储存和制备相关的分析前问题可能比实验室内的变化发挥更大的作用。在临床有效性方面,研究的差异取决于他们是检查了目前提供给患者的实际测试,还是检查了潜在的基因特征。几乎所有的Oncotype DX证据都是针对上市测试的,最有力的验证研究来自临床均匀人群的随机对照试验(NSABP-14)的一组。本研究表明,在标准预后指标中加入该试验具有临床意义。在临床异质性人群(例如,ER阳性和他莫昔芬治疗的混合)的研究中,对MammaPrint标记和测试本身进行了检查,并显示了临床相关的患者风险分类,但如果将其与传统指标结合使用,则不清楚有多少预测将跨越决策阈值。在一项研究中检查了BCP测试本身,并在几项研究中测试了各种配方的签名。一项随机对照试验提供了高质量的回顾性证据,证明Oncotype DX在预测化疗疗效方面的临床应用,但没有发现MammaPrint或H/I比值的临床应用证据。三个决策分析检查了乳腺癌基因表达测定的成本效益,总体上没有定论。结论:Oncotype DX在验证途径上走得最远,有强有力的回顾性证据表明,在一个定义明确的临床亚组中,与标准预测因子相比,它预测远处扩散和化疗益处的临床相关程度。使用MammaPrint的临床意义的证据并不像使用Oncotype DX那样明确,而且预测化疗获益的能力尚不存在。H/I比率测试需要进一步验证。对于所有的测试,在不同人群中预测和观察到的风险的关系仍然需要进一步的研究,正如他们的增量贡献,最佳实施以及与当前治疗的患者的相关性一样。
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引用次数: 0
Collection and use of cancer family history in primary care. 初级保健中癌症家族史的收集和使用。
Nadeem Qureshi, Brenda Wilson, Pasqualina Santaguida, June Carroll, Judith Allanson, Carolina Ruiz Culebro, Melissa Brouwers, Parminder Raina

Objectives: This systematic review was undertaken to: (1) evaluate the accuracy of patient reporting of cancer family history, (2) identify and evaluate tools designed to capture cancer family history that are applicable to the primary care setting, and (3) identify and evaluate risk assessment tools (RATs) in promoting appropriate management of familial cancer risk in primary care settings.

Data sources: MEDLINE, EMBASE, CINAHL, and Cochrane Central from 1990 to July 2007.

Review methods: Standard systematic review methodology was employed. Eligibility criteria included English studies evaluating breast, colorectal, ovarian, or prostate cancers. All primary study designs were included. For family history tools (FHxTs) and RATs, studies were limited to those applicable to primary care settings. RATs were excluded if they calculated the risk of mutation only, required specialist genetics knowledge, or were stand-alone guidelines.

Results: Reporting Accuracy: Of 19 eligible studies, 16 evaluated the accuracy of reporting family history and three on reliability. Reporting accuracy was better for relatives free of cancer (specificity) than those with cancer (sensitivity). Accuracy was better for breast and colorectal than for ovarian and prostate cancers. Family History Tools: Of 40 eligible studies, 18 FHxTs were applicable to primary care. Most collected information on more than one cancer, employed self-administered questionnaires, and favored paper-based formats to collate family information. Details collected were often focused on specific conditions and affected relatives. Eleven tools were evaluated relative to current practice and seven were not. Irrespective of study design, compared to best current practice (genetic interviews) and standard primary care practice (family history in medical records) the FHxTs performed well. Risk Assessment Tools: Of 15 eligible studies, three RATs were identified for patient use and eight for use by professionals. They were presented in a range of computer-based and paper-based formats, and preliminary evidence indicated potential efficacy, but not definitive effectiveness in practice.

Conclusions: Although limited in generalizability, informants reporting their cancer family history have greater accuracy for relatives free of cancer than those with cancer. Reporting accuracy may vary among different cancer types. FHxTs varied in the extent of family enquiry depending on the tool's purpose. These tools were primarily developed as an integral part of risk assessment. The few tools that were evaluated performed well against both best and standard clinical practice. A number of RATs designed for primary care settings exist, but evidence is lacking of their effectiveness in promoting recommended clinical actions.

目的:本系统综述旨在:(1)评估患者报告癌症家族史的准确性;(2)识别和评估用于捕获癌症家族史的工具,这些工具适用于初级保健机构;(3)识别和评估风险评估工具(RATs),以促进初级保健机构对家族性癌症风险的适当管理。数据来源:MEDLINE, EMBASE, CINAHL和Cochrane Central从1990年到2007年7月。评价方法:采用标准的系统评价方法。入选标准包括评估乳腺癌、结直肠癌、卵巢癌或前列腺癌的英文研究。所有的初步研究设计都被纳入。对于家族史工具(FHxTs)和大鼠,研究仅限于适用于初级保健机构的研究。如果大鼠只计算突变风险,需要专业的遗传学知识,或者是独立的指导方针,则将其排除在外。结果:报告准确性:在19项符合条件的研究中,16项评估报告家族史的准确性,3项评估可靠性。无癌亲属报告的准确性(特异性)优于有癌亲属报告的准确性(敏感性)。乳腺癌和结直肠癌的准确率高于卵巢癌和前列腺癌。家族史工具:在40项符合条件的研究中,18项FHxTs适用于初级保健。大多数人收集了不止一种癌症的信息,采用了自我管理的问卷,并倾向于以纸质形式整理家庭信息。收集的细节通常集中在具体情况和受影响的亲属上。11种工具相对于目前的实践进行了评估,7种没有。无论研究设计如何,与当前最佳实践(基因访谈)和标准初级保健实践(医疗记录中的家族史)相比,FHxTs表现良好。风险评估工具:在15项符合条件的研究中,确定了3项大鼠供患者使用,8项供专业人员使用。它们以一系列基于计算机和基于纸张的格式呈现,初步证据表明可能有效,但在实践中没有明确的有效性。结论:尽管在概括性上受到限制,但举报人报告其癌症家族史对无癌症亲属的准确性高于有癌症亲属。报告的准确性可能因不同的癌症类型而异。FHxTs的家庭调查范围因工具用途而异。这些工具最初是作为风险评估的一个组成部分而开发的。评估的少数工具在最佳和标准临床实践中都表现良好。存在一些为初级保健环境设计的大鼠,但缺乏证据表明它们在促进推荐的临床行动方面的有效性。
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Evidence report/technology assessment
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