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First- and Second- Generation Antipsychotics for Children and Young Adults [Entered Retrospectively]


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Statistics: 81 Studies, 4 Key Questions, 1 Extraction Form,
Date Published: Jul 23, 2015 02:29PM
Description: Methods: Two reviewers conducted study selection and quality assessment independently and resolved discrepancies by consensus. One reviewer extracted data, and a second reviewer verified the data. We conducted a descriptive analysis for all studies and performed metaanalyses when appropriate. Results: Eighty-one studies (64 trials and 17 cohort studies) examined the following conditions: pervasive developmental disorders (12 studies); attention deficit hyperactivity disorder (ADHD) or disruptive behavior disorders (8 studies); bipolar disorder (11 studies); schizophrenia and related psychosis (31 studies); Tourette syndrome (7 studies); behavioral issues (4 studies); and multiple conditions (9 studies). One study reported data on both bipolar disorder and schizophrenia. The majority of the trials had a high risk of bias. The methodological quality of the cohort studies was moderate. Results are presented by outcome below: Symptoms: The strength of evidence for all head-to-head comparisons of FGAs and SGAs was low or insufficient to draw conclusions. SGAs were favored over placebo for behavior symptoms (ADHD and disruptive behavior disorders), the Clinical Global Impressions scale (ADHD and disruptive behavior disorders, bipolar disorder, and schizophrenia), positive and negative symptoms (schizophrenia), and tics (Tourette syndrome) (moderate strength of evidence). Other short- and long-term outcomes: All head-to-head comparisons had low or insufficient strength of evidence. There was no significant difference between SGAs and placebo for suicide related behaviors (moderate strength of evidence). The evidence was rated as insufficient to draw conclusions for health-related quality of life, involvement with the legal system, and other patient-, parent-, or care provider-reported outcomes for all conditions. Adverse events: All outcomes comparing FGAs with SGAs had low or insufficient strength of evidence. Outcomes comparing FGAs versus FGAs and FGAs versus placebo had insufficient evidence. Risperidone was favored over olanzapine for dyslipidemia; olanzapine was favored over risperidone for prolactin-related events; and both quetiapine and risperidone were favored over olanzapine for weight gain (moderate strength of evidence). For nearly all outcomes and comparisons, placebo resulted in significantly fewer adverse events than SGAs. Subpopulations: Thirty-six studies examined the association between various patient subpopulations and outcomes. Most concluded that the results did not differ by subpopulations, or findings were discordant across studies. Conclusion: Evidence comparing FGAs with SGAs, various FGAs, and FGAs with placebo was very limited. Some SGAs appear to have a better side-effect profile than other SGAs. Compared with placebo, SGAs have better symptom improvement but more adverse events. Future high quality research examining head-to-head antipsychotic comparisons is needed.
Contributor(s): Jennifer C Seida, MPH; Janine Schouten, BSc; Shima S Mousavi, MD; Michele Hamm, MSc; Amy Beaith, MISt; Ben Vandermeer, MSc; Donna M Dryden, PhD; Khrista Boylan, MD, FRCPC; Amanda S Newton, RN, PhD; Normand Carrey, MD, FRCPC, ABPN
Funding Source: The Agency for Healthcare Research and Quality (AHRQ)
Methodology Description: We systematically searched the following bibliographic databases: MEDLINE, Embase, CENTRAL, PsycINFO, International Pharmaceutical Abstracts (IPA), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, ProQuest Dissertations International, MedEffect Canada, and TOXLINE. The searches are up to date to February 2011. We limited the searches to studies published from 1987 or later to coincide with the Diagnostic and Statistical Manual of Mental Disorders III–Revised. We restricted the search results to studies published in the English language. We applied filters to restrict the results to children and young adults ≤24 years of age and to trials and cohort studies. We hand searched proceedings of the following scientific meetings that were identified by our clinical experts: American Academy of Child and Adolescent Psychiatry (2007–2008), International College of Neuropsychopharmacology (2007–2009), and International Society for Bipolar Disorders (2007–2009). We searched clinical trial registers for ongoing studies and reference lists of relevant studies to identify additional studies. In addition, we contacted drug manufacturers to request published and unpublished study data. We reviewed FDA documents related to the eligible drugs to identify additional data. Two reviewers independently screened titles and abstracts using broad inclusion criteria. We retrieved the full text of all articles identified as "include" or "unclear." Two reviewers independently assessed each article using a priori inclusion criteria and a standardized form. We resolved disagreements by consensus or third-party adjudication. Randomized controlled trials (RCTs), nonrandomized controlled trials (NRCTs), and cohort studies that examined a condition of interest (pervasive developmental disorders, ADHD and disruptive behavior disorders, bipolar disorder, schizophrenia or schizophrenia-related psychosis, Tourette syndrome, obsessive-compulsive disorder, post-traumatic stress disorder, anorexia nervosa, or behavioral issues) in children or young adults ≤24 years of age were considered for inclusion. Eligible studies compared a FDA-approved FGA or SGA with any other antipsychotic or with placebo. Studies were required to report at least one outcome of interest including symptom improvement, other short- or long-term outcomes, or adverse events. No minimum follow-up duration was specified. One reviewer extracted data using a standardized form, and a second reviewer verified the data for accuracy and completeness. We extracted information on study characteristics, inclusion and exclusion criteria, participant characteristics, interventions, and outcomes. Reviewers resolved discrepancies by consensus or in consultation with a third party.

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Effectiveness of Early Diagnosis, Prevention, and Treatment of Clostridium difficile Infection [Entered Retrospectively]


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Statistics: 112 Studies, 10 Key Questions, 10 Extraction Forms,
Date Published: Jul 23, 2015 02:29PM
Description: Objectives: To conduct a systematic review and synthesize evidence for differences in the accuracy of diagnostic tests, and the effects of interventions to prevent and treat Clostridium difficile infection (CDI) in adult patients. Data Sources: Searching for relevant literature was conducted in MEDLINE, the Cochrane Library, and Allied and Complementary Medicine (AMED). ClinicalTrials.gov and expert consultants provided leads to additional studies. We also manually searched reference lists from relevant literature. Review Methods: Standard Evidence-based Practice Center methods were employed. Screening of abstracts and full text articles to identify studies meeting inclusion/exclusion criteria was performed by two independent reviewers. High-quality direct comparison studies were used to examine differences in diagnostic tests. Randomized controlled trials (RCTs) were used to examine comparative effectiveness of antibiotic treatment for CDI. Quality of data extraction was checked by separate reviewers. Quality ratings and strength of evidence grading was performed on included studies. Evidence on diagnostic tests was quantitatively synthesized focusing on differences between test sensitivities and specificities. Evidence on antibiotic treatment was quantitatively examined using pooled analysis. Qualitative narrative analysis was used to synthesize evidence from all available study types for environmental prevention and nonstandard prevention and treatment, with the exception of probiotics as primary prevention, for which a forest plot is provided. Results: Overall, literature was sparse and strength of evidence was generally low due to small sample sizes or lack of adequate controls. For diagnostic testing, direct comparisons of commercially available enzyme immunoassays for C. difficile toxins A and B did not find major differences in sensitivity or specificity. Limited evidence suggests that tests for genes related to the production of C. difficile toxins may be more sensitive than immunoassays for toxins A and B while the comparisons of these test specificities were inconsistent. Moderate evidence in favor of antibiotic restriction policies for prevention was found. Environmental preventive interventions such as glove use and disposable thermometers have limited evidence. However, this literature is largely based on controlling outbreaks. Use of multiple component interventions further limits the ability to synthesize evidence in a meaningful way. Numerous potential new forms of treatment are being examined in placebo controlled RCTs, case series, and case reports. For standard treatment, no antimicrobial is clearly superior for the initial cure of CDI. Recurrence is less frequent with fidaxomicin than with vancomycin. Monoclonal antibodies for prevention and fecal flora reconstitution for multiple recurrences appear promising. Conclusions: Given the frequency and severity of CDI and the fact that future reimbursement policy may withhold payment for hospital-acquired infections, this is an under-researched topic. More precise estimates of the magnitude of differences in test sensitivities and specificities are needed. More importantly, studies have not established that any of the possible differences in test accuracy would lead to substantially different patient outcomes in clinical practice. More research on effective treatment and unintended consequences of treatment, such as resistance, is needed. Gut flora may be important, but improved understanding of healthy gut ecology and the complex interactions is necessary before continuing to pursue probiotics.
Contributor(s): Mary Butler, PhD, MBA; Donna Bliss, RN, PhD; Dimitri Drekonja, MD; Gregory Filice, MD; Thomas Rector, PharmD, PhD; Roderick MacDonald, MS; Timothy Wilt, MD, MPH
Funding Source: The Agency for Healthcare Research and Quality (AHRQ)
Methodology Description: None Provided

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Benefits and Harms of Routine Preoperative Testing: Comparative Effectiveness Review 2013


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Statistics: 220 Studies, 4 Key Questions, 4 Extraction Forms,
Date Published: Jul 23, 2015 02:19PM
Description: Objectives: Preoperative testing is used to guide the action plan for patients undergoing surgical and other procedures that require anesthesia and to predict potential postoperative complications. There is uncertainty whether routine or per-protocol testing in the absence of a specific indication prevents complications and improves outcomes, or whether it causes unnecessary delays, costs, and harms due to false-positive results. Data sources: We searched MEDLINE® and Ovid Healthstar® (from inception to July 22, 2013), as well as Cochrane Central Trials Registry and Cochrane Database of Systematic Reviews. Review methods: We included comparative and cohort studies of both adults and children undergoing surgical and other procedures requiring either anesthesia or sedation (excluding local anesthesia). We included all preoperative tests that were likely to be conducted routinely (in all patients) or on a per-protocol basis (in selected patients). For comparative studies, the comparator of interest was either no testing or ad hoc testing done at the discretion of the clinician. We also looked for studies that compared routine and per-protocol testing. The outcomes of interest were mortality, perioperative events, complications, patient satisfaction, resource utilization, and harms related to testing. Results: Fifty-seven studies (14 comparative and 43 cohort) met inclusion criteria for the review. Well-conducted randomized controlled trials (RCTs) of cataract surgeries suggested that routine testing with electrocardiography, complete blood count, and/or a basic metabolic panel did not affect procedure cancellations (2 RCTs, relative risks [RRs] of 1.00 or 0.97), and there was no clinically important difference for total complications (3 RCTs, RR = 0.99; 95% confidence interval, 0.86 to 1.14). Two RCTs and six nonrandomized comparative studies of general elective surgeries in adults varied greatly in the surgeries and patients included, along with the routine or per-protocol tests used. They also mostly had high risk of bias due to lack of adjustment for patient and clinician factors, making their results unreliable. Therefore, they yielded insufficient evidence regarding the effect of routine or per-protocol testing on complications and other outcomes. There was also insufficient evidence for patients undergoing other procedures. No studies reported on quality of life, patient satisfaction, or harms related to testing. Conclusions: There is high strength of evidence that, for patients scheduled for cataract surgery, routine preoperative testing has no effect on total perioperative complications or procedure cancellation. There is insufficient evidence for all other procedures and insufficient evidence comparing routine and per-protocol testing. There is no evidence regarding quality of life or satisfaction, resource utilization, or harms of testing and no evidence regarding other factors that may affect the balance of benefits and harms. The findings of the cataract surgery studies are not reliably applicable to other patients undergoing other higher risk procedures. Except arguably for cataract surgery, numerous future adequately powered RCTs or well-conducted and analyzed observational comparative studies are needed to evaluate the benefits and harms of routine preoperative testing in specific groups of patients with different risk factors for surgical and anesthetic complications undergoing specific types of procedures and types of anesthesia.
Contributor(s): Ethan M Balk, MD, MPH; Amy Earley, BS; Nira Hadar, MS; Nirav Shah, MD; Thomas A Trikalinos, MD, PhD
Funding Source: National Eye Institute; National Institutes of Health (NIH); the Agency for Health Research and Quality (AHRQ).
Methodology Description: We conducted literature searches of studies in MEDLINE® and Ovid Healthstar® (inception – 22 July 2013), as well as the Cochrane Central Trials Registry® and Cochrane Database of Systematic Reviews® (through 2nd Quarter, 2013). The reference lists of prior systematic reviews and relevant guidelines were hand-searched. All citations were screened to identify articles relevant to each Key Question. The search included terms for surgical procedures, preoperative care, diagnostic tests, including the specific tests ECG, chest radiography, blood counts, coagulation tests, biochemistry, glucose, urinalysis, kidney function tests, liver function tests, pregnancy tests, hemoglobinopathies, and pulmonary function tests (see Appendix A for complete search strings). The EPC has developed a computerized screening program, Abstrackr, to automate the screening of abstracts for eligible articles for full-text screening (http://sunfire34.eecs.tufts.edu). Three team members double-screened all abstracts after an iterative training period to ensure that all screeners agreed upon the eligibility criteria. Abstrackr allowed us to label each citation as "accept," "reject," or "maybe." All abstracts with disagreements between readers or labeled as "maybe" were reconciled by the whole team in conference. Full-text articles were retrieved for all potentially relevant articles. These were rescreened for eligibility. All rejected articles were confirmed by the team leader. The reasons for excluding these articles are tabulated in Appendix B. Study eligibility was based on the following selection criteria: population and surgical procedure of interest, interventions (i.e., tests) and comparators of interest, outcomes of interest, and study designs. We did not consider outcomes when conducting abstract screening.

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