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Completed Systematic Reviews




Therapeutic Management, Delivery, and Postpartum Risk Assessment and Screening in Gestational Diabetes [Entered Retrospectively]


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Statistics: 43 Studies, 3 Key Questions, 3 Extraction Forms,
Date Published: Jul 23, 2015 02:40PM
Description: Objectives: We focused on four questions: (1) What are the risks and benefits of an oral diabetes agent (i.e., glyburide), as compared to all types of insulin, for gestational diabetes? (2) 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? (3) What risk factors are associated with the development of type 2 diabetes after gestational diabetes? (4) 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. Main Results: The search identified 45 relevant articles. The evidence indicated that (1) maternal glucose levels do not differ substantially in those treated with insulin versus insulin analogues or oral agents; (2) average infant birth weight may be lower in mothers treated with insulin than with glyburide; (3) induction at 38 weeks may reduce the macrosomia rate, with no increase in cesarean delivery rates; (4) anthropometric measures, fasting blood glucose (FBG), and 2-hour glucose value are the strongest risk factors associated with development of type 2 diabetes; (5) 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.
Contributor(s): Wanda K. Nicholson, MD, MPH, MBA; Lisa M. Wilson, ScM; Catherine Takacs Witkop, MD, MPH; Kesha Baptiste-Roberts, PhD, MPH; Wendy L. Bennett, MD, MPH; Shari Bolen, MD, MPH; Bethany B. Barone, ScM; Sherita Hill Golden, MD, MHS; Tiffany L. Gary, PhD; Donna M. Neale, MD; Eric B. Bass, MD, MPH
Funding Source: The Agency for Healthcare Research and Quality (AHRQ)
Methodology Description: We identified the primary literature on labor and postpartum management of gestational diabetes and the association with maternal and neonatal outcomes through a comprehensive search plan that included electronic and hand searching. We ran searches of the following databases for the specified periods of time: MEDLINE® (1950 through January 2007), EMBASE® (1974 through January 2007), The Cochrane Central Register of Controlled Trials (CENTRAL; Issue 1, 2007), and the Cumulative Index to Nursing & Allied Health Literature (CINAHL®; 1982 through January 2007). Hand searching for relevant citations took several forms. From our electronic search, we identified the 13 journals (see Appendix Ba) that were most likely to publish articles on this topic. We scanned the table of contents of each issue of these journals for relevant articles from August 2006 through January 2007. For the second form of hand searching, reviewers received eligible articles and flagged references of interest for the team to compare to the existing database. Two independent reviewers conducted title scans in a parallel fashion. If either reviewer thought that a title was potentially eligible, its abstract was reviewed. If the abstract was deemed to meet the inclusion criteria by two reviewers, the abstract was included in our article review. Any differences of opinion were resolved by the two primary reviewers or by a third independent reviewer. Each eligible article underwent double review by study investigators. A primary reviewer completed all data abstraction forms, and a second reviewer confirmed the first reviewer’s data abstraction forms for completeness and accuracy. The reviewers assessed study quality independently. Reviewer pairs were formed to include personnel with both clinical and methodological expertise. A third reviewer re-reviewed a random sample of articles by the first two reviewers to ensure consistency in the abstraction of the articles.

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The lack of evidence for PET or PET/CT surveillance of patients with treated lymphoma, colorectal cancer, and head and neck cancer


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Statistics: 12 Studies, 2 Key Questions, 1 Extraction Form,
Date Published: Jul 23, 2015 02:39PM
Description: Systematic review of diagnostic accuracy and clinical impact of PET and PET-CT used for surveillance in several cancer types
Contributor(s): Kamal Patel, Nira Hadar, Jounghee Lee, Barry A. Siegel, Bruce E. Hillner, Joseph Lau
Funding Source: National Cancer Institute Grand Opportunity Grant, RC2CA148259
Methodology Description: see manuscript for more details

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Second-Generation Antidepressants in the Pharmacologic Treatment of Adult Depression: An update of the 2007 Comparative Effectiveness Review [Entered Retrospectively]


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Statistics: 221 Studies, 2 Key Questions, 2 Extraction Forms,
Date Published: Jul 23, 2015 02:38PM
Description: Background: Depressive disorders such as major depressive disorder (MDD), dysthymia, and subsyndromal depression may be serious disabling illnesses. MDD affects more than 16 percent of adults at some point during their lifetimes. Second-generation antidepressants dominate the medical management of depressive disorders. These drugs include selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), and other drugs with related mechanisms of action that selectively target neurotransmitters. Objectives: The objective of this report was to compare the benefits and harms of bupropion, citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, fluvoxamine, mirtazapine, nefazodone, paroxetine, sertraline, trazodone, and venlafaxine for the treatment of depressive disorders, including variations of effects in patients with accompanying symptoms and patient subgroups. Data Sources: We updated a comparative effectiveness review published in 2007 by the Agency for Healthcare Research and Quality searching PubMed, Embase, The Cochrane Library, and International Pharmaceutical Abstracts up to January 2011. Review Methods: Two people independently reviewed the literature, abstracted data, and rated the risk of bias. If data were sufficient, we conducted meta-analyses of head-to-head trials of the relative benefit of response to treatment. In addition, we conducted mixed treatment comparisons to derive indirect estimates of the comparative efficacy among all second-generation antidepressants. Results: From a total of 3,722 citations, we identified 248 studies of good or fair quality. Overall, no substantial differences in efficacy could be detected among second-generation antidepressants for the treatment of acute-phase MDD. Statistically significant differences in response rates between some drugs are small and likely not clinically relevant. No differences in efficacy were apparent in patients with accompanying symptoms or in subgroups based on age, sex, ethnicity, or comorbidities, although evidence within these subpopulations was limited. Differences exist in the incidence of specific adverse events and the onset of action. Venlafaxine leads to higher rates of nausea and vomiting, sertraline to higher rates of diarrhea, and mirtazapine to higher rates of weight gain than comparator drugs. Bupropion causes lower rates of sexual dysfunction than other antidepressants. The evidence is insufficient to draw conclusions about the comparative efficacy and effectiveness for the treatment of dysthymia and subsyndromal depression. Conclusions: Our findings indicate that the existing evidence does not warrant the choice of one second-generation antidepressant over another based on greater efficacy and effectiveness. Differences with respect to onset of action and adverse events may be taken into consideration for the choice of a medication.
Contributor(s): Gerald Gartlehner, MD, MPH; Richard A. Hansen, PhD; Laura C. Morgan, MA; Kylie Thaler, MD, MPH; Linda J. Lux, MPA; Megan Van Noord, MSIS; Ursula Mager, PhD, MPH; Bradley N. Gaynes, MD, MPH; Patricia Thieda, MA; Michaela Strobelberger, MA; Stacey Lloyd, MPH; Ursula Reichenpfader, MD, MPH; Kathleen N. Lohr, PhD
Funding Source: The Agency for Healthcare Research and Quality (AHRQ)
Methodology Description: We have made only a few changes to the methods used for the CER published in 2007. They involve drugs, approaches to the literature searches, articles included or excluded, techniques for quantitative synthesis, and grading strength of evidence for the overall body of evidence. Specific changes are noted here; longer documentation will be found in later parts of this methods chapter. We added one drug—desvenlafaxine—to the literature searches and analyses (we used the same search strategy in electronic databases as for the original report). For manual literature searches, we changed the process to semi-automatic searches using the ScopusTM abstraction and citation database (www.scopus.com/home.url). The method is described below in the section on Literature Searches. We did not make any changes to the eligibility criteria (Table 4 in the Introduction). We used the same approach as in the 2007 report to select literature, assess the quality of individual studies (i.e., appraise their risk for bias), and extract relevant data. Despite using identical methods to select relevant evidence, however, we removed some studies in the 2007 report from the current update. These studies had not met eligibility criteria in the 2007 report to begin with, but because they represented the only available evidence to answer a particular question at the time we had retained them. In the 2007 report we also had briefly summarized findings of such studies to provide a synopsis of the best available evidence (best- evidence approach). When, for this update, we have identified newer evidence that meets our eligibility criteria, we excluded the other "ineligible" studies from the current update. For indirect comparisons we changed our statistical methods. Specifically, we now use a Bayesian mixed-treatment comparisons approach rather than meta-regressions and network meta-analyses. A detailed description of this approach appears in the section below on Data Synthesis. We changed our method for rating the strength of evidence. In 2007 we used the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach. For this update, we follow the principles outlined for use by the AHRQ Evidence-based Practice Centers in AHRQ’s Methods Guide for Effectiveness and Comparative Effectiveness Reviews20 (www.effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and- reports/?pageaction=displayproduct&productid=318). Details are summarized below in Grading Strength of a Body of Evidence.

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Procedures for Managing Postpartum Hemorrhage: A Systematic Review


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Statistics: 73 Studies, 5 Key Questions, 2 Extraction Forms,
Date Published: Jul 23, 2015 02:37PM
Description: None Provided
Contributor(s): Nila A. Sathe, MA, MLIS Jessica Young, MD, MPH Frances E. Likis, DrPH, NP, CNM, FACNM, FAAN Daphne Carlson-Bremer, DVM. PhD Alicia Morgans, MD Jeff Andrews, MD
Funding Source: None Provided
Methodology Description: None Provided

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Pain Management Injection Therapies for Low-back Pain [Entered Retrospectively]


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Statistics: 92 Studies, 7 Key Questions, 1 Extraction Form,
Date Published: Jul 23, 2015 02:36PM
Description: Structured Abstract Objectives. Low back pain is common and injections with corticosteroids are a frequently used treatment option. This report reviews the current evidence on effectiveness and harms of epidural, facet joint, and sacroiliac corticosteroid injections for low back pain conditions. Data Sources. A prior systematic review (searches through July 2008), electronic databases (Ovid MEDLINE, Scopus, and the Cochrane Libraries from January 2008 through October 2014), reference lists, and clinical trials registries. Review Methods. Using predefined criteria, we selected randomized trials of patients with lumbosacral radiculopathy, spinal stenosis, nonradicular back pain, or chronic postsurgical back pain that compared effectiveness or harms of epidural, facet joint, or sacroiliac corticosteroid injections versus placebo or other interventions. We also included randomized trials that compared different injection techniques and large (sample sizes >1000) observational studies of back injections that reported harms. The quality of included studies was assessed, data were extracted, and results were summarized qualitatively and using meta-analysis on outcomes stratified by immediate- (1 week to <2 weeks), short- (2 weeks to <3 months), intermediate- (3 months to <1 year), and long-term (>1 year) followup. Results. Seventy-eight randomized trials of epidural injections, 13 trials of facet joint injections, and one trial of sacroiliac injections were included. For epidural corticosteroid injections versus placebo interventions for radiculopathy, the only statistically significant effects were on mean improvement in pain at immediate-term followup (weighted mean difference [WMD] ‒7.55 on a 0 to 100 scale, 95% CI ‒11.4 to ‒3.74) (strength of evidence [SOE]: moderate), mean improvement in function at immediate-term followup when an outlier trial was excluded (standardized mean difference [SMD] ‒0.33, 95% CI ‒0.56 to ‒0.09) (SOE: low), and risk of surgery at short-term followup (relative risk [RR] 0.62, 95% CI 0.41 to 0.92) (SOE: low). The magnitude of effects on pain and function was small, did not meet predefined thresholds for minimum clinically important differences, and there were no differences on outcomes at longer-term followup. Evidence on effects of different injection techniques, patient characteristics, or comparator interventions estimates was limited and did not show clear effects. Trials of epidural corticosteroid injections for radiculopathy versus nonplacebo interventions did not clearly demonstrate effectiveness (SOE: insufficient to low). Evidence was limited for epidural corticosteroid injections versus placebo interventions for spinal stenosis (SOE: low to moderate) or nonradicular back pain (SOE: low), but showed no differences in pain, function, or likelihood of surgery. Studies found no clear differences between various facet joint corticosteroid injections (intra-articular, extra-articular [peri-capsular], or medial branch) and placebo interventions (SOE: low to moderate). There was insufficient evidence from one very small trial to determine effects of peri-articular sacroiliac joint corticosteroid injections injection (SOE: insufficient). Serious harms from injections were rare in randomized trials and observational studies, but harms reporting was suboptimal (SOE: low). Conclusions: Epidural corticosteroid injections for radiculopathy were associated with immediate improvements in pain and might be associated with immediate improvements in function, but benefits were small and not sustained, and there was no effect on long-term risk of surgery. Evidence did not suggest that effectiveness varies based on injection technique, corticosteroid, dose, or comparator. Limited evidence suggested that epidural corticosteroid injections are not effective for spinal stenosis or nonradicular back pain and that facet joint corticosteroid injections are not effective for presumed facet joint pain. There was insufficient evidence to evaluate effectiveness of sacroiliac joint corticosteroid injections.
Contributor(s): Roger Chou, MD, FACP Robin Hashimoto, PhD Janna Friedly, MD Rochelle Fu, PhD Tracy Dana, MLS Sean Sullivan, PhD Christina Bougatsos, MPH Jerry Jarvik, MD, MPH
Funding Source: Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. HHSA 290-2012-00014-I.) Rockville, MD: Agency for Healthcare Research and Quality; March 2015. www.effectivehealthcare.ahrq.gov/reports/final.cfm
Methodology Description: Review Methods. Using predefined criteria, we selected randomized trials of patients with lumbosacral radiculopathy, spinal stenosis, nonradicular back pain, or chronic postsurgical back pain that compared effectiveness or harms of epidural, facet joint, or sacroiliac corticosteroid injections versus placebo or other interventions. We also included randomized trials that compared different injection techniques and large (sample sizes >1000) observational studies of back injections that reported harms. The quality of included studies was assessed, data were extracted, and results were summarized qualitatively and using meta-analysis on outcomes stratified by immediate- (1 week to <2 weeks), short- (2 weeks to <3 months), intermediate- (3 months to <1 year), and long-term (>1 year) followup.)

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