Despite wide use in clinical practice, acupuncture remains a controversial treatment for chronic pain. Our objective was to update an individual patient data meta-analysis to determine the effect ...size of acupuncture for 4 chronic pain conditions. We searched MEDLINE and the Cochrane Central Registry of Controlled Trials randomized trials published up until December 31, 2015. We included randomized trials of acupuncture needling versus either sham acupuncture or no acupuncture control for nonspecific musculoskeletal pain, osteoarthritis, chronic headache, or shoulder pain. Trials were only included if allocation concealment was unambiguously determined to be adequate. Raw data were obtained from study authors and entered into an individual patient data meta-analysis. The main outcome measures were pain and function. An additional 13 trials were identified, with data received for a total of 20,827 patients from 39 trials. Acupuncture was superior to sham as well as no acupuncture control for each pain condition (all P < .001) with differences between groups close to .5 SDs compared with no acupuncture control and close to .2 SDs compared with sham. We also found clear evidence that the effects of acupuncture persist over time with only a small decrease, approximately 15%, in treatment effect at 1 year. In secondary analyses, we found no obvious association between trial outcome and characteristics of acupuncture treatment, but effect sizes of acupuncture were associated with the type of control group, with smaller effects sizes for sham controlled trials that used a penetrating needle for sham, and for trials that had high intensity of intervention in the control arm. We conclude that acupuncture is effective for the treatment of chronic pain, with treatment effects persisting over time. Although factors in addition to the specific effects of needling at correct acupuncture point locations are important contributors to the treatment effect, decreases in pain after acupuncture cannot be explained solely in terms of placebo effects. Variations in the effect size of acupuncture in different trials are driven predominantly by differences in treatments received by the control group rather than by differences in the characteristics of acupuncture treatment.
Acupuncture is effective for the treatment of chronic musculoskeletal, headache, and osteoarthritis pain. Treatment effects of acupuncture persist over time and cannot be explained solely in terms of placebo effects. Referral for a course of acupuncture treatment is a reasonable option for a patient with chronic pain.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Decision curve analysis is a novel method for evaluating diagnostic tests, prediction models and molecular markers. It combines the mathematical simplicity of accuracy measures, such as sensitivity ...and specificity, with the clinical applicability of decision analytic approaches. Most critically, decision curve analysis can be applied directly to a data set, and does not require the sort of external data on costs, benefits and preferences typically required by traditional decision analytic techniques.
In this paper we present several extensions to decision curve analysis including correction for overfit, confidence intervals, application to censored data (including competing risk) and calculation of decision curves directly from predicted probabilities. All of these extensions are based on straightforward methods that have previously been described in the literature for application to analogous statistical techniques.
Simulation studies showed that repeated 10-fold crossvalidation provided the best method for correcting a decision curve for overfit. The method for applying decision curves to censored data had little bias and coverage was excellent; for competing risk, decision curves were appropriately affected by the incidence of the competing risk and the association between the competing risk and the predictor of interest. Calculation of decision curves directly from predicted probabilities led to a smoothing of the decision curve.
Decision curve analysis can be easily extended to many of the applications common to performance measures for prediction models. Software to implement decision curve analysis is provided.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Full text
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
15.
Screening for Prostate Cancer Carlsson, Sigrid V; Vickers, Andrew J
The Medical clinics of North America,
11/2020, Volume:
104, Issue:
6
Journal Article
Peer reviewed
Open access
This article gives an overview of the current state of the evidence for prostate cancer early detection with prostate-specific antigen (PSA) and summarizes current recommendations from guideline ...groups. The article reviews the global public health burden and risk factors for prostate cancer with clinical implications as screening tools. Screening studies, novel biomarkers, and MRI are discussed. The article outlines 7 key practice points for primary care physicians and provides a simple schema for facilitating shared decision-making conversations.
Overdiagnosis is a problem for prostate cancer because it is often coupled with overtreatment. Because of the proximity of the prostate to the bladder, penis, and rectum, curative treatment often ...leads to long-term urinary, sexual, and bowel symptoms. ...men will experience similar treatment-related morbidity from surgery or radiotherapy as men with intermediate- or highrisk disease, for whom treatment is clearly indicated. In sum, application of some basic medical principles-avoiding screening, biopsy, or treatment in patients who are unlikely to benefit-coupled with recent findings on prostate cancer can transform PSA screening. ...our question is not whether to screen for prostate cancer, but whether US medicine is prepared to make a few simple changes to ensure that we screen well. Carlsson S, Assel M, Sjoberg D, Ulmert D, Hugosson J, Lilja H, Vickers A. Influence of blood prostate specific antigen levels at age 60 on benefits and harms of prostate cancer screening: population-based cohort study.
Prostate-specific antigen (PSA) was discovered in the 1970s, with assays to detect PSA in blood approved by the US Food and Drug Administration in 1986. Almost from the very beginning, its role as a ...prostate cancer marker has been severely misunderstood. One of the most well-known misconceptions is that prostate cancer detectable by elevated PSA in asymptomatic men requires treatment, irrespective of stage and grade. Accordingly, when PSA testing to detect prostate cancer began in the United States in the late 1980s and early 1990s, most men with elevated PSA were biopsied and nearly all cancers detected were treated. It is estimated that in its first 20 years of use, PSA screening led to >1 million Americans suffering harm from radiotherapy or surgery to treat a cancer that would never become apparent before they died of another cause (1).More than 35 years later, PSA continues to be misunderstood. Here, we try to correct 8 common contemporary misconceptions about PSA. In brief, PSA may have a bad reputation, but it has remarkable properties—when used correctly—that make the clinical biochemistry of prostate cancer the envy of all other solid tumors.
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