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Completed Systematic Reviews




Breastfeeding Programs and Policies, Breastfeeding Uptake, and Maternal Health Outcomes in Developed Countries


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Statistics: 147 Studies, 2 Key Questions, 2 Extraction Forms,
Date Published: Mar 21, 2019 09:12AM
Description: The goal of this project is to summarize the effectiveness of community, workplace, and health care system–based programs and policies aimed at supporting and promoting breastfeeding and determine the association between breastfeeding and maternal health.
Contributor(s): Cynthia Feltner, M.D., M.P.H. Rachel Palmieri Weber, Ph.D. Alison Stuebe, M.D., M.Sc. Catherine A. Grodensky, M.P.H. Colin Orr, M.D. Meera Viswanathan, Ph.D.
Funding Source: This report was funded by the Office on Women’s Health at the Office of the Assistant Secretary for Health (OASH) and the Centers for Disease Control and Prevention (CDC) through an interagency agreement with the Agency for Healthcare Research and Quality (AHRQ)
Methodology Description: We searched PubMed/MEDLINE, the Cochrane Library, and CINAHL from January 1, 1980, to October 12, 2017, for studies relevant to the effectiveness of health care system–based, workplace, and community breastfeeding programs and policies. For evidence on breastfeeding and maternal health, we updated the 2007 Agency for Healthcare Research and Quality report on this topic and searched the same databases from November 1, 2005, to October 12, 2017. For studies of breastfeeding programs and policies, trials, systematic reviews, and observational studies with a control group were eligible; we excluded primary care–based programs delivered as part of routine care. For studies related to breastfeeding and maternal health, we included systematic reviews, case-control and cohort studies. Pairs of reviewers independently selected, extracted data from, and rated the risk of bias of relevant studies; they graded the strength of evidence (SOE) using established criteria. We synthesized all evidence qualitatively.

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Diet-Related Fibers and Human Health Outcomes, Version 3.1 (Retired)


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Statistics: 991 Studies, 1 Key Question, 1 Extraction Form,
Date Published: Mar 21, 2019 09:12AM
Description: The objectives of this database are to: 1. Systematically compile and provide access to primary, English-language, peer-reviewed science linking dietary fiber intake in humans to one or more of 10 potential health benefits 2. Provide researchers with a tool to understand how different fibers are characterized in studies 3. Facilitate researchers in identifying gaps in the current research 4. Create a database to serve as a starting foundation of primary human literature for conducting evidence-based reviews and meta-analyses 5. Efficiently assist researchers in identifying fibers of interest. This database should serve as a foundation for future work. Specific inclusion and exclusion criteria, detailed in the user manual, were applied in determining database eligibility; thus, this database is not intended to serve as a sole source for identifying all possible fiber literature for the purposes of conducting a meta-analysis or systematic review. This database contains Population, Intervention, Comparator, and Outcome (PICO) data to help users formulate and narrow the focus of their research question. It is expected that secondary searches will be conducted to augment this database.
Contributor(s): Nicola McKeown (PI), Mei Chung (Co-I), Kara Livingston (Project & Data Manager), Caleigh Sawicki, Danielle Haslam, Deena Wang, Caitlin Blakeley, Yinan Jia, Nicole Baruch, Micaela Karlsen, Carrie Brown
Funding Source: International Life Sciences Institute – North America branch (ILSI-NA)
Methodology Description: Please see user manual.

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Assessment Tools for Palliative Care


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Statistics: 213 Studies, 4 Key Questions, 1 Extraction Form,
Date Published: Mar 21, 2019 09:12AM
Description: Technical Brief
Contributor(s): Rebecca Aslakson, M.D., Ph.D. Sydney M. Dy, M.D., M.S. Renee F. Wilson, M.S. Julie M. Waldfogel, Pharm.D. Allen Zhang, B.S. Sarina R. Isenberg, M.A. Alex Blair, M.D. Joshua Sixon, B.S. Karen A. Robinson, Ph.D.
Funding Source: AHRQ
Methodology Description: First, we engaged Key Informants representing both patient/caregiver and provider/researcher perspectives to help guide the project. We then sought systematic reviews of palliative care assessment tools and applications of tools through searches of PubMed, CINAHL, Cochrane, PsycINFO and PsycTESTS from January 1, 2007 to August 29, 2016. We conducted supplemental searches of information on palliative care tools, including comprehensive reviews published prior to our date limitation, Web sites, and a targeted search for primary articles to identify tools where no recent high-quality systematic review was identified. We organized tools by the eight domains (subdomains) from the National Consensus Project Clinical Practice Guidelines for Palliative Care: structure and process, physical, psychological and psychiatric, social (caregiver), spiritual and religious, cultural, care at the end of life (bereavement), ethical and legal; as well as a ninth domain for multidimensional tools (quality of life and patient experience).

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Systematic review of the adverse bone and calcium balance effects of caffeine consumption in healthy adults, pregnant women, adolescents, and children


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Statistics: 14 Studies, 1 Key Question, 1 Extraction Form,
Date Published: Mar 21, 2019 09:12AM
Description: To date, one of the most heavily cited assessments of caffeine safety in the peer-reviewed literature is that issued by Health Canada (Nawrot et al., 2003). Since then, >10,000 papers have been published related to caffeine, including hundreds of reviews on specific human health effects; however, to date, none have compared the wide range of topics evaluated by Nawrot et al. (2003). Thus, as an update to this foundational publication, we conducted a systematic review of data on potential adverse effects of caffeine published from 2001 to June 2015. Subject matter experts and research team participants developed five PECO (population, exposure, comparator, and outcome) questions to address five types of outcomes (acute toxicity, cardiovascular toxicity, bone and calcium effects, behavior, and development and reproduction) in four healthy populations (adults, pregnant women, adolescents, and children) relative to caffeine intake doses determined not to be associated with adverse effects by Health Canada (comparators: 400 mg/day for adults [10 g for lethality], 300 mg/day for pregnant women, and 2.5 mg/kg/day for children and adolescents). The a priori search strategy identified >5000 articles that were screened, with 381 meeting inclusion/exclusion criteria for the five outcomes (pharmacokinetics was addressed contextually, adding 46 more studies). Data were extracted by the research team and rated for risk of bias and indirectness (internal and external validity). Selected no- and low-effect intakes were assessed relative to the population-specific comparator. Conclusions were drawn for the body of evidence for each outcome, as well as endpoints within an outcome, using a weight of evidence approach. When the total body of evidence was evaluated and when study quality, consistency, level of adversity, and magnitude of response were considered, the evidence generally supports that consumption of up to 400 mg caffeine/day in healthy adults is not associated with overt, adverse cardiovascular effects, behavioral effects, reproductive and developmental effects, acute effects, or bone status. Evidence also supports consumption of up to 300 mg caffeine/day in healthy pregnant women as an intake that is generally not associated with adverse reproductive and developmental effects. Limited data were identified for child and adolescent populations; the available evidence suggests that 2.5 mg caffeine/kg body weight/day remains an appropriate recommendation. The results of this systematic review support a shift in caffeine research to focus on characterizing effects in sensitive populations and establishing better quantitative characterization of interindividual variability (e.g., epigenetic trends), subpopulations (e.g., unhealthy populations, individuals with preexisting conditions), conditions (e.g., coexposures), and outcomes (e.g., exacerbation of risk-taking behavior) that could render individuals to be at greater risk relative to healthy adults and healthy pregnant women. This review, being one of the first to apply systematic review methodologies to toxicological assessments, also highlights the need for refined guidance and frameworks unique to the conduct of systematic review in this field.
Contributor(s): None Provided
Funding Source: The systematic review of the adverse bone and calcium balance effects of caffeine consumption in healthy adults, pregnant women, adolescents, and children is sponsored by the North American Branch of the International Life Sciences Institute (ILSI) Caffeine Working Group. Unrestricted grants from the American Beverage Association (ABA) and the National Coffee Association (NCA) were also received.
Methodology Description: Problem formulation was based on providing an update of Nawrot et al. (2003), “Effects of caffeine on human health,” [PMID 12519715]. No comprehensive studies of similar scope have been published in the peer-reviewed literature, and thus the overall objective is to conduct an update to Nawrot et al. that applies the rigor of a systematic review. This review is one of five systematic reviews being conducted simultaneously (other endpoints include acute toxicity and adverse effects on reproduction/development, cardiovascular, and bone and calcium balance outcomes. Exposure and comparators were thus based on levels determined by Nawrot et al., (2003). Searches: The searches were conducted using: PubMed, EMBASE, and the Cochrane Database of Systematic Review. The restrictions will be articles published in English between 2001 and June 8, 2015. EMBASE searches were exclusive of MEDLINE and restricted to selected journals (430 journals were selected based on relevance). The Cochrane library was searched between Jan 2001 and June 2015 for review articles. Search strategies were informed and reviewed by a librarian. Types of studies included: All study types (excluding case studies) characterizing a quantitative exposure to caffeine and an adverse bone and calcium balance endpoint will be included. Both exposure and response must be evaluated at the individual level. Reviews will not be included in the systematic assessment (unless original data, such as a meta analysis, were conducted), but selected reviews will be consulted for context. Include: studies reporting parameters or effects associated with adverse effects within a benefit/therapy study. Exclude: Studies assessing only beneficial or therapeutic endpoints or outcomes following exposure to caffeine. Participants/ population: Populations: healthy adults, healthy pregnant women, healthy adolescents (aged 12-19), healthy children (aged 3-12). Exposure: = 400 mg/day, 300 mg/day, 2.5 mg/kg-bw day*, respectively (by population). Comparator: < 400 mg/day, 300 mg/day, 2.5 mg/kg-bw day*, respectively (by population). *Applies to both adolescents and children. Include: Studies evaluating a healthy population; this will include athletes, military, and pregnant women, unless otherwise noted as unhealthy. Healthy in this context was defined as subjects who were not specifically described as hospitalized, diagnosed with disease, and/or receiving medical treatment for a disease at the time of the study. Include: Studies that evaluate the effects of caffeine exposure in humans. This included studies in which healthy individuals were included as a control group (or similar) as part of a study on unhealthy populations (only information from the healthy individuals would be carried forward). Include: crossover balance studies could with a control period rather than a control group. Exclude: Studies evaluating unhealthy populations with no healthy control arm; this includes asthmatics and smoking populations. Exclude: Studies that describe effects of caffeine exposure in animal species or in vitro studies. Exclude: Case studies with no comparison group. Intervention(s), exposure(s) Exposure to caffeine: = 400 mg/day, 300 mg/day, 2.5 mg/kg-bw day*, respectively (by population). *Applies to both adolescents and children. Include: Studies that provide a quantitative exposure to a caffeine source associated with an adverse effect. Acceptable forms of caffeine are coffee, tea, chocolate, cola-type beverages, energy drinks (e.g. Monster, Red Bull, Rockstar), supplements, medicines, energy shots, caffeinated chewing gum, caffeinated sport gel, and caffeinated sport bars. Include: Studies evaluating the effects of caffeine alone, in one of the aforementioned forms, or in combination with one or more compounds occurring in the approved sources at levels designed to match constituents of valid sources (e.g., caffeine and green tea extract). Exclude: Studies that do not provide a quantitative exposure to an acceptable caffeine source associated with an adverse effect. This includes studies that evaluate only decaffeinated coffee/tea and caffeine placebo exposures (i.e. exposures where participants were expecting caffeine but did not receive the drug), Yerba mate, guarana, damiana and/or contaminants of caffeine or caffeine metabolites. Exclude: Studies that evaluate the effects of caffeine in combination with another pharmacologically active compound in an OTC medicine such as Excedrin (acetaminophen + caffeine) or in a prescribed drug, alcohol, or nicotine. Exclude: Studies less than six months in duration. Six months is the minimum time needed to see bone outcome endpoint effects on most any intervention (this does not include balance studies). Comparator(s)/ control: Comparator: < 400 mg/day, 300 mg/day, 2.5 mg/kg-bw day*, respectively (by population) *Applies to both adolescents and children Outcome(s): Primary outcomes Adverse bone and calcium balance effects include, effects on bone fracture, bone mineral density, calcium absorption and any other adverse bone and calcium balance effects reported (inclusive investigation). Exclude: Studies assessing hypertension and menopausal symptoms (not considered adverse). Studies addressing rare bone disorders like Paget’s disease, Osteoporosis Imperfecta, etc. Secondary outcomes Pharmacokinetic data that could be used to interpret the primary outcome (e.g., contextual information). Risk of bias (quality) assessment: Risk of bias will be evaluated using the U.S. National Toxicology Program: Office of Health Assessment and Translation Risk of Bias Rating Tool for Human and Animal studies (2015). Study reliability will also be characterized using the systematic approach for evaluating and scoring human data proposed by Money et al (2013) [PMID 23579077] Strategy for data synthesis: The body of evidence was evaluated and integrated using the U.S. National Toxicology Program: Office of Health Assessment and Translation Handbook for Conducting a Literature-Based Health Assessment Using OHAT Approach for Systematic Review an Evidence Integration (2015). The process will involve generation of evidence tables and a qualitative synthesis of the available data. Evidence analysts will use a weight of evidence approach incorporating concepts such as consistency, dose response, imprecision, indirectness, magnitude of effect, confounding, and risk of bias to determine conclusions regarding levels of caffeine associated with acute adverse effects. Analytical tools, such as forest plots and descriptive statistical parameters, were used to aid in the weight of evidence assessment. Based on the availability of data, considerations were also be made regarding the severity of the outcome as well as the event(s) relative to the progression of the outcome.

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Stroke Prevention in Patients With Atrial Fibrillation: A Systematic Review Update


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Statistics: 185 Studies, 3 Key Questions, 1 Extraction Form,
Date Published: Mar 21, 2019 09:12AM
Description: Objectives: This review updates previous reviews regarding the optimal risk stratification tools for stroke and bleeding prediction and treatment options for stroke prevention. Data Sources: We searched PubMed®, Embase®, and the Cochrane Database of Systematic Reviews for relevant English-language comparative studies published from January 1, 2000, to February 14, 2018. Review Methods: Two investigators screened each abstract and full-text article for inclusion, abstracted data, rated quality and applicability, and graded evidence. When possible, random-effects models were used to compute summary estimates of effects.
Contributor(s): Gillian D. Sanders, Ph.D. Angela Lowenstern, M.D. Ethan Borre, B.A. Ranee Chatterjee, M.D., M.P.H. Adam Goode, D.P.T., Ph.D. Lauren Sharan, M.D. Nancy M. Allen LaPointe, Pharm.D., M.H.S. Giselle Raitz, M.D. Bimal Shah, M.D., M.B.A. Roshini Yapa, M.B.B.S. J. Kelly Davis, B.A. Kathryn Lallinger, M.S.L.S. Robyn Schmidt, B.A. Andrzej Kosinski, Ph.D. Sana Al-Khatib, M.D. M.H.S.
Funding Source: Agency for Healthcare Research and Quality (AHRQ), The Patient-Centered Outcomes Research Institute (PCORI)
Methodology Description: We searched PubMed®, Embase®, and the Cochrane Database of Systematic Reviews for relevant English-language comparative studies published from January 1, 2000, to February 14, 2018. Two investigators screened each abstract and full-text article for inclusion, abstracted the data, and performed quality ratings and evidence grading. Random-effects models were used to compute summary estimates of effects. See the review protocol (https://effectivehealthcare.ahrq.gov/topics/stroke-afib-update/research-protocol) for full details.

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