Nonnutritive sweeteners, such as aspartame, sucralose and stevioside, are widely consumed, yet their long-term health impact is uncertain. We synthesized evidence from prospective studies to ...determine whether routine consumption of non-nutritive sweeteners was associated with long-term adverse cardiometabolic effects.
We searched MEDLINE, Embase and Cochrane Library (inception to January 2016) for randomized controlled trials (RCTs) that evaluated interventions for nonnutritive sweeteners and prospective cohort studies that reported on consumption of non-nutritive sweeteners among adults and adolescents. The primary outcome was body mass index (BMI). Secondary outcomes included weight, obesity and other cardiometabolic end points.
From 11 774 citations, we included 7 trials (1003 participants; median follow-up 6 mo) and 30 cohort studies (405 907 participants; median follow-up 10 yr). In the included RCTs, nonnutritive sweeteners had no significant effect on BMI (mean difference -0.37 kg/m
; 95% confidence interval CI -1.10 to 0.36;
9%; 242 participants). In the included cohort studies, consumption of nonnutritive sweeteners was associated with a modest increase in BMI (mean correlation 0.05, 95% CI 0.03 to 0.06;
0%; 21 256 participants). Data from RCTs showed no consistent effects of nonnutritive sweeteners on other measures of body composition and reported no further secondary outcomes. In the cohort studies, consumption of nonnutritive sweeteners was associated with increases in weight and waist circumference, and higher incidence of obesity, hypertension, metabolic syndrome, type 2 diabetes and cardiovascular events. Publication bias was indicated for studies with diabetes as an outcome.
Evidence from RCTs does not clearly support the intended benefits of nonnutritive sweeteners for weight management, and observational data suggest that routine intake of nonnutritive sweeteners may be associated with increased BMI and cardiometabolic risk. Further research is needed to fully characterize the long-term risks and benefits of nonnutritive sweeteners.
PROSPERO-CRD42015019749.
ObjectivesTo provide a comprehensive systematic overview of current evidence from pooled analyses/meta-analyses and systematic reviews (PMASRs) pertaining to dairy consumption and incident cancer ...and/or all-cause or cancer-specific mortality.DesignOverview of reviews.SettingCommunity setting.ParticipantsThe unit of analysis is PMASRs. A total of 42 PMASRs was included in this overview of reviews.Interventions/exposuresAny dairy product consumption (eg, milk, yogurt, etc).Primary and secondary outcomes measuresPrimary outcome measure is development of any type of cancer. Secondary outcome measures are all-cause mortality and cancer-specific mortality.ResultsFrom 9693 citations identified, we included 42 PMASRs (52 study reports) published between 1991 and 2017. Thirty-one (74%) of these was pooled analyses/meta analyses, and only 11 (26%) were systematic reviews and meta-analyses. There was a wide variability in the type of study designs included within the other PMASRs, thus contributing to variable and, in instances, divergent estimates of cancer risk for several cancer subtypes. For example, only one systematic review and meta-analysis exclusively included prospective study designs. Most PMASRs were of low to moderate quality based on the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) scores. The median AMSTAR score was 5 (IQR 2–7). Our overview identified conflicting evidence from PMASRs on association between dairy consumption and incident cancers or mortality. Heterogeneity in summary estimates reflected the inclusion of variable study designs and overall low methodological quality of individual PMASRs.ConclusionsThe association between dairy consumption and cancer risk has been explored in PMASRs with a variety of study designs and of low to moderate quality. To fully characterise valid associations between dairy consumption and risk of cancer and/or mortality rigorously conducted, PMASRs including only high-quality prospective study designs are required.Trial registration numberCRD42017078463.
There is a plethora of interventions and policies aimed at changing practice habits of primary healthcare professionals, but it is unclear which are the most appropriate, sustainable, and effective. ...We aimed to evaluate the evidence on behavior change interventions and policies directed at healthcare professionals working in primary healthcare centers.
Study design: overview of reviews.
MEDLINE (Ovid), Embase (Ovid), The Cochrane Library (Wiley), CINAHL (EbscoHost), and grey literature (January 2005 to July 2015).
two reviewers independently, and in duplicate, identified systematic reviews, overviews of reviews, scoping reviews, rapid reviews, and relevant health technology reports published in full-text in the English language.
two reviewers extracted data pertaining to the types of reviews, study designs, number of studies, demographics of the professionals enrolled, interventions, outcomes, and authors' conclusions for the included studies. We evaluated the methodological quality of the included studies using the AMSTAR scale. For the comparative evaluation, we classified interventions according to the behavior change wheel (Michie et al.).
Of 2771 citations retrieved, we included 138 reviews representing 3502 individual studies. The majority of systematic reviews (91%) investigated behavior and practice changes among family physicians. Interactive and multifaceted continuous medical education programs, training with audit and feedback, and clinical decision support systems were found to be beneficial in improving knowledge, optimizing screening rate and prescriptions, enhancing patient outcomes, and reducing adverse events. Collaborative team-based policies involving primarily family physicians, nurses, and pharmacists were found to be most effective. Available evidence on environmental restructuring and modeling was found to be effective in improving collaboration and adherence to treatment guidelines. Limited evidence on nurse-led care approaches were found to be as effective as general practitioners in patient satisfaction in settings like asthma, cardiovascular, and diabetes clinics, although this needs further evaluation. Evidence does not support the use of financial incentives to family physicians, especially for long-term behavior change.
Behavior change interventions including education, training, and enablement in the context of collaborative team-based approaches are effective to change practice of primary healthcare professionals. Environmental restructuring approaches including nurse-led care and modeling need further evaluation. Financial incentives to family physicians do not influence long-term practice change.
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Nonnutritive sweetener (NNS) consumption is increasing among children, yet its long-term health impact is unclear, particularly when exposure occurs during early life.
To synthesize evidence from ...prospective studies evaluating the association of early-life NNS exposure and long-term metabolic health.
Medline, Embase, and Cochrane Library (inception to July 2015).
We aimed to include randomized controlled trials (RCTs) evaluating NNS-based interventions and prospective cohort studies reporting NNS exposure among pregnant women, infants, or children (<12 years of age), with a minimum study duration of 6 months.
The primary outcome was BMI; secondary outcomes included growth velocity, overweight/obesity, adiposity, and adverse metabolic effects. Study quality and risk of bias were evaluated using validated assessment tools.
We identified 6 eligible cohort studies and 2 RCTs (n = 15,641 children). Half of the cohorts reported increasing weight gain or fat mass accumulation with increasing NNS intake, and pooled data from 2 cohorts showed a significant correlation with BMI gain (weighted mean correlation 0.023, 95% confidence interval 0.006 to 0.041). RCTs reported contradictory effects on weight change in children receiving NNSs. No eligible studies evaluated prenatal or infant NNS exposure.
Meta-analysis was limited because of the small number of eligible studies and heterogeneity of populations and outcomes.
There is limited and inconsistent evidence of the long-term metabolic effects of NNS exposure during gestation, infancy, and childhood. Further research is needed to inform recommendations for the use of NNSs in this sensitive population.
Background
Asthma management guidelines recommend low‐dose inhaled corticosteroids (ICS) as first‐line therapy for adults and adolescents with persistent asthma. The addition of anti‐leukotriene ...agents to ICS offers a therapeutic option in cases of suboptimal control with daily ICS.
Objectives
To assess the efficacy and safety of anti‐leukotriene agents added to ICS compared with the same dose, an increased dose or a tapering dose of ICS (in both arms) for adults and adolescents 12 years of age and older with persistent asthma. Also, to determine whether any characteristics of participants or treatments might affect the magnitude of response.
Search methods
We identified relevant studies from the Cochrane Airways Group Specialised Register of Trials, which is derived from systematic searches of bibliographic databases including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, PsycINFO, the Allied and Complementary Medicine Database (AMED), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the trial registries clinicaltrials.gov and ICTRP from inception to August 2016.
Selection criteria
We searched for randomised controlled trials (RCTs) of adults and adolescents 12 years of age and older on a maintenance dose of ICS for whom investigators added anti‐leukotrienes to the ICS and compared treatment with the same dose, an increased dose or a tapering dose of ICS for at least four weeks.
Data collection and analysis
We used standard methods expected by Cochrane. The primary outcome was the number of participants with exacerbations requiring oral corticosteroids (except when both groups tapered the dose of ICS, in which case the primary outcome was the % reduction in ICS dose from baseline with maintained asthma control). Secondary outcomes included markers of exacerbation, lung function, asthma control, quality of life, withdrawals and adverse events.
Main results
We included in the review 37 studies representing 6128 adult and adolescent participants (most with mild to moderate asthma). Investigators in these studies used three leukotriene receptor antagonists (LTRAs): montelukast (n = 24), zafirlukast (n = 11) and pranlukast (n = 2); studies lasted from four weeks to five years.
Anti‐leukotrienes and ICS versus same dose of ICS
Of 16 eligible studies, 10 studies, representing 2364 adults and adolescents, contributed data. Anti‐leukotriene agents given as adjunct therapy to ICS reduced by half the number of participants with exacerbations requiring oral corticosteroids (risk ratio (RR) 0.50, 95% confidence interval (CI) 0.29 to 0.86; 815 participants; four studies; moderate quality); this is equivalent to a number needed to treat for additional beneficial outcome (NNTB) over six to 16 weeks of 22 (95% CI 16 to 75). Only one trial including 368 participants reported mortality and serious adverse events, but events were too infrequent for researchers to draw a conclusion. Four trials reported all adverse events, and the pooled result suggested little difference between groups (RR 1.06, 95% CI 0.92 to 1.22; 1024 participants; three studies; moderate quality). Investigators noted between‐group differences favouring the addition of anti‐leukotrienes for morning peak expiratory flow rate (PEFR), forced expiratory volume in one second (FEV1), asthma symptoms and night‐time awakenings, but not for reduction in β2‐agonist use or evening PEFR.
Anti‐leukotrienes and ICS versus higher dose of ICS
Of 15 eligible studies, eight studies, representing 2008 adults and adolescents, contributed data. Results showed no statistically significant difference in the number of participants with exacerbations requiring oral corticosteroids (RR 0.90, 95% CI 0.58 to 1.39; 1779 participants; four studies; moderate quality) nor in all adverse events between groups (RR 0.96, 95% CI 0.89 to 1.03; 1899 participants; six studies; low quality). Three trials reported no deaths among 834 participants. Results showed no statistically significant differences in lung function tests including morning PEFR and FEV1 nor in asthma control measures including use of rescue β2‐agonists or asthma symptom scores.
Anti‐leukotrienes and ICS versus tapering dose of ICS
Seven studies, representing 1150 adults and adolescents, evaluated the combination of anti‐leukotrienes and tapering‐dose of ICS compared with tapering‐dose of ICS alone and contributed data. Investigators observed no statistically significant difference in % change from baseline ICS dose (mean difference (MD) ‐3.05, 95% CI ‐8.13 to 2.03; 930 participants; four studies; moderate quality), number of participants with exacerbations requiring oral corticosteroids (RR 0.46, 95% CI 0.20 to 1.04; 542 participants; five studies; low quality) or all adverse events (RR 0.95, 95% CI 0.83 to 1.08; 1100 participants; six studies; moderate quality). Serious adverse events occurred more frequently among those taking anti‐leukotrienes plus tapering ICS than in those taking tapering doses of ICS alone (RR 2.44, 95% CI 1.52 to 3.92; 621 participants; two studies; moderate quality), but deaths were too infrequent for researchers to draw any conclusions about mortality. Data showed no improvement in lung function nor in asthma control measures.
Authors' conclusions
For adolescents and adults with persistent asthma, with suboptimal asthma control with daily use of ICS, the addition of anti‐leukotrienes is beneficial for reducing moderate and severe asthma exacerbations and for improving lung function and asthma control compared with the same dose of ICS. We cannot be certain that the addition of anti‐leukotrienes is superior, inferior or equivalent to a higher dose of ICS. Scarce available evidence does not support anti‐leukotrienes as an ICS sparing agent, and use of LTRAs was not associated with increased risk of withdrawals or adverse effects, with the exception of an increase in serious adverse events when the ICS dose was tapered. Information was insufficient for assessment of mortality.
Delays in reperfusion for patients with myocardial ischemia leads to increased morbidity and mortality. The objective of this review was to identify, evaluate, and critically appraise the evidence on ...whether pre-hospital electrocardiography (ECG) reduces patient mortality and improves post—ST-segment myocardial infarction patient-oriented outcomes.
We searched PubMed/MEDLINE, EMBASE, and Cochrane Library (1990-2015) for controlled clinical studies. We also searched conference proceedings, trial registries, and reference lists of narrative and systematic reviews. Two reviewers independently identified and extracted data from studies that compared pre-hospital ECG with standard of care in patients with suspected myocardial infarction who underwent primary percutaneous coronary intervention. Internal validity was assessed using the Newcastle-Ottawa scale.
We screened 21,197 citations and included 63 unique studies (plus 22 companion publications). Most studies were of moderate quality. Pre-hospital ECG was associated with significantly fewer deaths (relative risk, 0.68; 95% confidence interval CI, 0.63-0.74; 45 studies; 71,315 patients; I2, 0%), reduced time to reperfusion (mean difference, −35.32 minutes; 95% CI, −44.02 to −26.61; 26 studies; 27,524 patients; I2, 97%), shorter hospital stays (mean difference, −0.63 days; 95% CI, −1.05 to −0.20; 10 studies; 39,275 patients; I2, 39%), and more patients had first medical contact to device time < 90 minutes than standard of care (relative risk, 1.77; 95% CI, 1.52-2.07; 11 studies; 20,991patients; I2, 93%).
Use of pre-hospital ECG is associated with decreased mortality and overall better patient outcomes.
Les retards de reperfusion chez les patients atteints d’une ischémie myocardique mènent à l’augmentation de la morbidité et de la mortalité. L’objectif de cette revue était de déterminer, d’évaluer et d’apprécier de manière critique les données probantes de manière à savoir si l’électrocardiographie (ECG) préhospitalier réduit la mortalité chez les patients et améliore les résultats cliniques axés sur le patient ayant subi un infarctus du myocarde avec sus-décalage du segment ST.
Nous avons cherché des études comparatives dans PubMed/MEDLINE, EMBASE et la Bibliothèque Cochrane (1990-2015). Nous avons également cherché des procès-verbaux de conférences, des registres d’essais et des listes de référence de revues narratives et systématiques. Deux examinateurs ont indépendamment déterminé et extrait les données d’études qui comparaient l'ECG prehospitalier à la norme de soins des patients montrant une suspicion d’infarctus du myocarde qui subissaient une intervention coronarienne percutanée primaire. La validité interne était évaluée à l’aide de l’échelle Newcastle-Ottawa.
Nous avons sélectionné 21 197 citations et inclus 63 études distinctes (et en plus 22 publications complémentaires). La plupart des études étaient de qualité modérée. L’ECG préhospitalier était associé à une diminution significative du nombre de décès (risque relatif, 0,68; intervalle de confiance IC à 95 %, 0,63-0,74; 45 études; 71 315 patients; I2, 0 %), à une réduction du temps de reperfusion (différence moyenne, −35,32 minutes; IC à 95 %, −44,02 à −26,61; 26 études; 27 524 patients; I2, 97 %), à des séjours à l’hôpital plus courts (différence moyenne, −0,63 jour; IC à 95 %, −1,05 à −0,20; 10 études; 39 275 patients; I2, 39 %), et un plus grand nombre de patients avaient un premier contact médical avant la mise en place du dispositif < 90 minutes comparativement à la norme de soins (risque relatif, 1,77; IC à 95 %, 1,52-2,07; 11 études; 20 991 patients; I2, 93 %).
L’utilisation de l’ECG préhospitalier est associée à la diminution de la mortalité et à des résultats cliniques globalement meilleurs chez les patients.
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The appropriate approach for weight loss among children and adolescents with overweight and obesity remains unclear.
To evaluate the difference in the treatment outcomes associated with behavioral ...weight loss interventions led by laypersons and professionals in comparison with unsupervised control arms among children and adolescents with overweight and obesity.
For this systematic review and meta-analysis, the Medical Literature Analysis and Retrieval System Online (MEDLINE), Embase, the Cochrane Library, and Cumulative Index of Nursing and Allied Health Literature (CINAHL) databases were searched from January 1, 1996, to June 1, 2019.
Included in this study were randomized clinical trials (RCTs) of behavioral interventions lasting at least 12 weeks for children and adolescents (aged 5-18 years) with overweight and obesity. Exclusion criteria included non-RCT studies, interventions lasting less than 12 weeks, adult enrollment, participants with other medical diagnoses, pharmacological treatment use, and articles not written in English. Two of 6 reviewers independently screened all citations. Of 25 586 citations, after duplicate removal, 78 RCTs (5780 participants) met eligibility criteria.
A bayesian framework and Markov chain Monte Carlo simulation methods were used to combine direct and indirect associations. Random-effects and fixed-effect network meta-analysis models were used with the preferred model chosen by comparing the deviance information criteria. This study was registered with the International Prospective Register of Systematic Reviews (PROSPERO) and followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline.
The immediate and sustained changes in weight and body mass index (BMI) standardized mean difference (SMD) were primary outcomes planned before data collection began, whereas waist circumference and percent body fat were secondary outcomes. The hypothesis being tested was formulated before the data collection.
Of 25 586 citations retrieved, we included 78 RCTs (5780 participants), with a follow-up of 12 to 104 weeks. Compared with the control condition, random-effects models revealed that professional-led weight loss interventions were associated with reductions in weight (mean difference MD, -1.60 kg 95% CI, -2.30 to -0.99 kg; 68 trials; P < .001) and BMI (SMD, -0.30 95% CI, -0.39 to -0.20; 59 trials; P < .001) that were not sustained long term (weight MD, -1.02 kg 95% CI, -2.20 to 0.34 kg; 21 trials; P = .06; BMI SMD, -0.12 95% CI, -0.46 to 0.21; 20 trials; P < .001). There was no association between layperson-led interventions and weight loss in the short-term (MD, -1.40 kg 95% CI, -3.00 to 0.26 kg; 5 trials; P = .05) or long-term (MD, -0.98 kg 95% CI, -3.60 to 1.80 kg; 1 trial; P = .23) compared with standard care. No difference was found in head-to-head trials (professional vs layperson MD, -0.25 kg 95% CI -1.90 to 1.30 kg; 5 trials; P = .38).
This systematic review and meta-analysis found that professional-led weight loss interventions were associated with short-term but not sustained weight reduction among children and adolescents with overweight or obesity, and the evidence for layperson-led approaches was insufficient to draw firm conclusions.
Return on investment in healthcare leadership development programs Jeyaraman, Maya M; Qadar, Sheikh Muhammad Zeeshan; Wierzbowski, Aleksandra ...
International journal of health care quality assurance incorporating Leadership in health services,
02/2018, Volume:
31, Issue:
1
Journal Article
Peer reviewed
Purpose
Strong leadership has been shown to foster change, including loyalty, improved performance and decreased error rates, but there is a dearth of evidence on effectiveness of leadership ...development programs. To ensure a return on the huge investments made, evidence-based approaches are needed to assess the impact of leadership on health-care establishments. As a part of a pan-Canadian initiative to design an effective evaluative instrument, the purpose of this paper was to identify and summarize evidence on health-care outcomes/return on investment (ROI) indicators and metrics associated with leadership quality, leadership development programs and existing evaluative instruments.
Design/methodology/approach
The authors performed a scoping review using the Arksey and O’Malley framework, searching eight databases from 2006 through June 2016.
Findings
Of 11,868 citations screened, the authors included 223 studies reporting on health-care outcomes/ROI indicators and metrics associated with leadership quality (73 studies), leadership development programs (138 studies) and existing evaluative instruments (12 studies). The extracted ROI indicators and metrics have been summarized in detail.
Originality/value
This review provides a snapshot in time of the current evidence on ROI indicators and metrics associated with leadership. Summarized ROI indicators and metrics can be used to design an effective evaluative instrument to assess the impact of leadership on health-care organizations.
Abstract Background Delays in reperfusion for patients with myocardial ischemia leads to increased morbidity and mortality. The objectives of this review was to identify, evaluate and ...critically-appraise the evidence on whether pre-hospital ECG reduces patient mortality and improves post-STEMI patient-oriented outcomes. Methods We searched PubMed/MEDLINE, EMBASE and Cochrane Library (1990 to 2015) for controlled clinical studies. We also searched conference proceedings, trial registries and reference lists of narrative and systematic reviews. Two reviewers independently identified and extracted data from studies comparing pre-hospital ECG with standard of care in patients with suspected myocardial infarction undergoing primary percutaneous coronary intervention. Internal validity was assessed using the Newcastle-Ottawa scale. Results We screened 21,197 citations and included 63 unique studies (plus 22 companion publications). Most studies were of moderate quality. Pre-hospital ECG was associated with significantly fewer deaths (relative risk (RR) 0.68, 95% confidence intervals (CI) 0.63 to 0.74; 45 studies; 71,315 patients; I 2 0%), reduced time-to-reperfusion (MD -35.32 minutes, 95% CI -44.02 to -26.61; 26 studies; 27,524 patients; I 2 97%), shorter hospital stays (mean difference (MD) -0.63 days, 95% CI -1.05 to -0.20; 10 studies; 39,275 patients; I 2 39%), and more patients had first medical contact-to-device time less than 90 minutes than standard of care (RR 1.77, 95% CI 1.52 to 2.07; 11 studies; 20,991patients; I 2 93% ). Conclusions Use of pre-hospital ECG is associated with decreased mortality and overall better patient outcomes.
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More than a decade of fighting in the Democratic Republic of the Congo (DRC) has resulted in extensive human rights abuses, of which sexual and gender-based violence (SGBV) is one of the most salient ...and disturbing features. This paper uses qualitative data, based on 10 focus groups with 86 women and men to better understand gendered community perspectives on SGBV and its consequences in South Kivu. We conclude that for many survivors, rape has consequences far beyond the physiological and psychological trauma associated with the attack. Respondents say sexual violence has become a societal phenomenon, in which the community isolation and shame experienced as a result of the attack become as important as concerns about the attack itself. Male focus group participants explain their own feelings of shame and anger associated with knowing their female relatives were raped. These findings highlight the complexity of community reintegration for survivors and identify a number of programmatic and policy implications, such as the need for counselling for survivors of sexual violence with their families as well as individually; the importance of income-generating training; and the need for improved justice mechanisms to bring perpetrators to justice.
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