Management of Depression in Patients With Cancer: A Clinical Practice Guideline. Systematic Reviews: Synthesis of Best Evidence for Clinical Decisions Managing behavioural and psychological symptoms in community dwelling older people with dementia: 1. A systematic review of the effectiveness of interventions Impact of non-pharmacological interventions on prevention and treatment of delirium in critically ill patients: protocol for a systematic review of quantitative and qualitative research Upper gastrointestinal bleeding Checklists of methodological issues for review authors to consider when including non-randomized studies in systematic reviews. UK clinical guideline for the prevention and treatment of osteoporosis Is the Comparison between Exercise and Pharmacologic Treatment of Depression in the Clinical Practice Guideline of the American College of Physicians Evidence-Based? Effectiveness of manual therapies: the UK evidence report Sugammadex: when should we be giving it? Effect of vitamin D supplementation on inflammation: protocol for a systematic review Quality of Life and Treatment Outcome in Panic Disorder: Cognitive Behavior Group Therapy Effects in Patients Refractory to Medication Treatment Issues in psychopharmacology. One-year follow-up of pharmacotherapy-resistant patients with panic disorder treated with cognitive-behavior therapy: Outcome and predictors of remission. Psychosocial interventions for people with dementia: An overview and commentary on recent developments What's in a name? The challenge of describing interventions in systematic reviews: analysis of a random sample of reviews of non-pharmacological stroke interventions Whole-body vibration training in obese subjects: A systematic review Wasted research when systematic reviews fail to provide a complete and up-to-date evidence synthesis: the example of lung cancer Bias in Systematic Reviews? Updated systematic review of exercise studies in breast cancer survivors: attention to the principles of exercise training Psychoeducational treatment for school-aged children with bipolar disorder. Quality of reporting of harms in randomised controlled trials of pharmacological interventions for rheumatoid arthritis: a systematic review Diagnosing COPD and supporting smoking cessation in general practice: evidence–practice gaps
PURPOSE This report up date s the Cancer Care Ontario Program in Evidence -Based Care guideline for the management of  depression in adult patients with cancer . This guideline covers pharmacologic , psychological , and collaborative care interventions , with a focus on integrating practical management tools to assist clinicians in delivering appropriate treatments for depression in patients with cancer . METHODS Recommendations were developed by synthesizing information from extant guidelines and review s and search ing for r and omized controlled trials from the date of data base inception ( 1964 for MEDLINE and 1974 for EMBASE ) to January 2015 . Quality assessment of guidelines and systematic review s were conducted by using the Appraisal of Guidelines for Research and Evaluation II ( AGREE II ) , Assessment of Multiple Systematic Review s ( AMSTAR ) , and Cochrane Risk of Bias tools . Final recommendations were developed through a st and ardized Program in Evidence -Based Care multidisciplinary expert and knowledge user review process . RESULTS Two high- quality relevant clinical practice guidelines , eight pharmacologic trials , nine psychological trials , and eight collaborative care intervention trials composed the evidence base upon which the recommendations were developed . Eight specific recommendations were made to establish a st and ard of care for the management of depression in patients with cancer . The recommendations and practical management tools were review ed as being well organized and helpful , although systemic barriers to implementation were identified . CONCLUSION This up date d guideline supports the previous general recommendation that patients with cancer who have depression may benefit from psychological and /or pharmacologic interventions , without evidence for the superiority of any specific treatment over another . New recommendations for a collaborative care model that incorporates a stepped care approach suggest that multidisciplinary mental health care restructuring may be required for optimal management of depression At the end of a long week in the office , you sink back into your chair , reflecting on some of the more memorable patients you cared for and counseled . Through gentle history taking , you discovered that urinary incontinence is the underlying cause of an elderly patient 's increasing social isolation . During a careful physical examination , you detected bruising on the torso of a woman with chronic headaches and began to explore the longst and ing abusive relationship between the woman and her alcoholic partner . You discontinued procainamide therapy in a 72-year-old man who had asymptomatic premature ventricular contractions after myocardial infa rct ion . To prevent bleeding from esophageal varices , you started -blocker therapy in a woman with long-st and ing cryptogenic cirrhosis and portal hypertension . In couples ' therapy , discussing the future quality of life of a middle-aged gay man with human immunodeficiency virus infection , you journeyed through emotionally intense dialogue about advance directives . You presented the risk factors for major and minor bleeding to a 39-year-old woman who was considering warfarin therapy because of recently diagnosed atrial fibrillation and valvular heart disease . You listened to , made diagnoses for , treated , advised , and comforted many patients . Yet there were some hiccoughs in your practice along the way . You stumbled while debating the pros and cons of breast cancer screening with a healthy 48-year-old woman who has been staying current with information on the Internet . You question ed the merits of a personalized walking program suggested to you by a motivated 66-year-old man with severe claudication . Explaining that you wanted to review the best current evidence on these issues , you resolved to address your uncertainties before these patients made their next office visits , in a week 's time . Sighing deeply , you acknowledge that you have little time to read . You subscribe to three journals , which you browse months after they arrive-either when your journal stack becomes precariously high or when your guilt is sufficiently motivational . You sometimes find the conclusions of individual articles conflicting or confusing . You know that some of the decisions and suggestions you made this week , specifically your decisions about stopping procainamide therapy and starting -blocker therapy and your advice about bleeding risks from anticoagulant therapy , were based on the best current research evidence [ 1 - 3 ] . On the other h and , your patients ' inquiries about breast cancer screening and exercise treatment for claudication highlight your need for a concise , current , rigorous synthesis of the best available evidence on each of these topics : in brief , a systematic review [ 4 , 5 ] . Incorporating Research Evidence into Clinical Decision Making The foregoing scenario is familiar to practitioners . In a typical week , we encounter patients with diverse problems ; exercise numerous clinical , interpersonal , and technical skills ; and make many decisions . The factors that affect these decisions and their outcomes are complex . For instance , each patient has unique sociodemographic characteristics , cultural circumstances , and personal preferences . Each physician has unique knowledge , experiences , and values . Moreover , practitioners and their patients make decisions within the context of a rapidly changing health care system that influences the availability , accessibility , and cost of diagnostic tests and therapies [ 6 ] . Timely , useful evidence from the biomedical literature should be an integral component of clinical decision making . If one treatment has been shown to be better than another , we need to know , so that we can recommend the treatment to the appropriate patients . The worldwide effort to develop new tests and treatments , and to determine their usefulness , has never been stronger , and our patients and their families expect us to be fonts of the knowledge that results from this effort [ 7 ] . Unfortunately , it is easy for current best research evidence to pass us by [ 8 ] . We may lack the time , motivation , and basic skills needed to find , critically appraise , and synthesize information , all of which we must do if we are to integrate the results of original studies into our practice . Fortunately , several potent methods are emerging that can greatly enhance our ability to interpret and apply research evidence ; foremost among them is the systematic review . This article begins a series in Annals that will examine systematic review s in detail and explore their many applications . Systematic review s represent the best chance that most practitioners will have to underst and and accurately apply the key signals arising from the robust and increasingly productive search for solutions to medical problems . A properly conducted systematic review faithfully summarizes the evidence from all relevant studies on the topic of interest , and it does so concisely and transparently . What Is a Systematic Review ? Systematic review s are scientific investigations in themselves , with pre-planned methods and an assembly of original studies as their subjects . They synthesize the results of multiple primary investigations by using strategies that limit bias and r and om error [ 9 , 10 ] . These strategies include a comprehensive search of all potentially relevant articles and the use of explicit , reproducible criteria in the selection of articles for review . Primary research design s and study characteristics are appraised , data are synthesized , and results are interpreted . When the results of primary studies are summarized but not statistically combined , the review may be called a qualitative systematic review . A quantitative systematic review , or meta- analysis , is a systematic review that uses statistical methods to combine the results of two or more studies . The term overview is sometimes used to denote a systematic review , whether quantitative or qualitative . Summaries of research that lack explicit descriptions of systematic methods are often called narrative review s. Review articles are one type of integrative publication ; practice guidelines , economic evaluations , and clinical decision analyses are others . These other types of integrative articles often incorporate the results of systematic review s. For example , practice guidelines are systematic ally developed statements intended to assist practitioners and patients with decisions about appropriate health care for specific clinical circumstances [ 11 ] . Evidence -based practice guidelines are based on systematic review s of the literature , appropriately adapted to local circumstances and values . Economic evaluations compare both the costs and the consequences of different courses of action ; the knowledge of consequences that are considered in these evaluations is often generated by systematic review s of primary studies . Decision analyses quantify both the likelihood and the valuation of the expected outcomes associated with competing alternatives . Differences between Systematic and Narrative Review s All review s , narrative and systematic alike , are retrospective , observational research studies and are therefore subject to systematic and r and om error . Accordingly , the quality of a review - and thus its worth-depends on the extent to which scientific review methods have been used to minimize error and bias . This is the key feature that distinguishes traditional narrative review s from systematic review s ( Table 1 ) . If a review is prepared according to the steps outlined in the right column of Table 1 , it is more likely to be systematic and to provide unbiased conclusions . If review methods approximate those found in the middle column of Table 1 , the article is more likely to be a narrative review , and the conclusions are less likely to be based on an unbiased summary of all relevant evidence . Table 1 . Differences between Narrative Review s and Systematic Review s Systematic review s are generated to answer specific , often narrow , clinical questions in depth . These questions can be formulated explicitly according to four variables : a specific population and setting ( such as elderly out patients ) , the condition of interest ( for example , hypertension ) , an exposure to a test or treatment ( such as pharmacologic management ) , and one or more specific outcomes ( such as cardiovascular and cerebrovascular events and mortality ) [ 12 ] . Thus , an example of a well-formulated , clinical ly relevant question is , Does pharmacologic treatment of hypertension in the elderly prevent strokes and myocardial infa rct ions or delay death ? If the question that is driving the review is not clear from the title , abstract , or introduction , or if no methods section is included , the paper is more likely to be a narrative review than a systematic review [ 13 ] . Most narrative review articles deal with a broad range of issues related to a given topic rather than addressing a particular issue in depth [ 9 ] . For example , a narrative review on diabetes ( such as that which might be found in a textbook chapter ) might include sections on the physiology and pathophysiology of carbohydrate , lipid , and protein metabolism ; the epidemiology of and prognosis associated with diabetes ; diagnostic and screening approaches ; and preventive , therapeutic , rehabilitative , and palliative interventions . Thus , narrative review s may be most useful for obtaining a broad perspective on a topic ; they are less often useful in furnishing quantitative answers to specific clinical questions . Narrative review s are appropriate for describing the history or development of a problem and its management . Narrative review s may better describe cutting-edge developments if research is scant or preliminary or if studies are very limited by flawed design or execution [ 13 ] . They may be particularly useful for discussing data in light of underlying theory and context . Narrative review s can draw analogies and can conceptually integrate two independent fields of research , such as Background Two-thirds of people living with dementia live at home in the UK and many experience distressing behavioural and psychological symptoms . This systematic review evaluates the effectiveness of non-pharmacological interventions for behavioural and psychological symptoms among community-dwelling people living with dementia . Methods This two-stage review undertook an initial mapping of the literature followed by a systematic review of relevant r and omised controlled trials . We search ed electronic data bases for pertinent studies reporting outcomes from interventions from January 2000 to March 2015 and up date d search es in October 2016 . We included studies that considered behavioural and psychological symptom management for older people living with dementia who live at home and excluded studies conducted in long-term care setting s. This paper presents findings from a narrative synthesis of 48 r and omised controlled trials evaluating interventions for people living with dementia alone , family carers alone and patient-carer dyads . Results We retrieved 17,871 de-duplicated records and screened them for potential inclusion . Evidence from 48 r and omised controlled trials suggests that family carer training and educational programmes that target problem behaviours and potential triggers can improve outcomes . Nurses and occupational therapists appear to help people with dementia with behavioural and psychological symptoms , but professional comparisons are lacking and there is no shared language about or underst and ing of behavioural and psychological symptoms amongst professionals , or between professionals and family carers . Conclusions Future research should focus on the effectiveness of components of multi-faceted programmes and their cost effectiveness and include qualitative data to better target interventions for behavioural and psychological symptoms . It is important to consider family carer readiness to use non-pharmacological strategies and to develop a shared language about the inherent needs and communications of behavioural and psychological symptoms Background Critically ill patients have an increased risk of developing delirium during their intensive care stay . To date , pharmacological interventions have not been shown to be effective for delirium management but non-pharmacological interventions have shown some promise . The aim of this systematic review is to identify effective non-pharmacological interventions for reducing the incidence or the duration of delirium in critically ill patients . Methods We will search MEDLINE , EMBASE , CINAHL , Web of Science , AMED , psycINFO and the Cochrane Library . We will include studies of critically ill adults and children . We will include r and omised trials and controlled trials which measure the effectiveness of one or more non-pharmacological interventions in reducing incidence or duration of delirium in critically ill patients . We will also include qualitative studies that provide an insight into patients and their families ’ experiences of delirium and non-pharmacological interventions . Two independent review ers will assess studies for eligibility , extract data and appraise quality . We will conduct meta-analyses if possible or present results narratively . Qualitative studies will also be review ed by two independent review ers , and a specially design ed quality assessment tool incorporating the CASP framework and the POPAY framework will be used to assess quality . Discussion Although non-pharmacological interventions have been studied in population s outside of intensive care units and multicomponent interventions have successfully reduced incidence and duration of delirium , no systematic review of non-pharmacological interventions specifically targeting delirium in critically ill patients have been undertaken to date . This systematic review will provide evidence for the development of a multicomponent intervention for delirium management of critically ill patients that can be tested in a subsequent multicentre r and omised trial . Systematic review registration PROSPERO Purpose of review This review discusses key issues in the management of upper gastrointestinal bleeding including patient preparation , sedation , hemostatic techniques , disposition , and recommended pharmacologic interventions . Recent findings Optimal resuscitation before endoscopy and proper pharmacologic interventions after endoscopy seem to be as crucial to the management of patients with upper gastrointestinal bleeding as meticulous hemostatic techniques during the procedure . In a retrospective evaluation of patients with upper gastrointestinal bleeding , multivariate analysis demonstrated significantly reduced morbidity and mortality in those who underwent aggressive preendoscopic resuscitation . In a prospect i ve , r and omized clinical trial , patients who received intravenous proton pump inhibitor therapy after endoscopic intervention  had a significantly reduced rebleeding rate compared with their placebo control group . Summary The algorithms described in this review can be applied clinical ly today and should directly lead to improved outcome . Nevertheless , even with the latest care available , results are not optimal . This review points to two major areas where we can benefit from improvement : primary hemostasis and recurrent bleeding . By pointing to these limitations , it is hoped that this review can help stimulate research in the field by applying new technologies to solve these problems . Endoscopic ultrasound , for example , could be used to help identify feeding vessels that can be treated endoscopically , thus potentially decreasing the incidence of failed primary hemostasis .  Endoscopic suturing , when more fully developed , may provide a better hemostatic technique that can reduce the incidence of recurrent bleeding . It is only through these review s that our state of knowledge in the field can be constantly reevaluated to up date today 's clinician with the latest knowledge and stimulate tomorrow 's research ers with challenging problems BACKGROUND There is increasing interest from review authors about including  non-r and omized studies  ( NRS ) in their systematic review s of health care interventions . This series from the Ottawa Non-R and omized Studies Workshop consists of six papers identifying method ological issues when doing this . AIM To format the guidance from the preceding papers on study design and bias , confounding and meta- analysis , selective reporting , and applicability/directness into checklists of issues for review authors to consider when including NRS in a systematic review . CHECKLISTS Checklists were devised providing frameworks to describe/assess : ( 1 ) study design s based on study design features ; ( 2 ) risk of residual confounding and when to consider meta-analysing data from NRS ; ( 3 ) risk of selective reporting based on the Cochrane framework for detecting selective outcome reporting in trials but extended to selective reporting of analyses ; and ( 4 ) directness of evidence contributed by a study to aid integration of NRS findings into summary of findings tables . SUMMARY The checklists described will allow review groups to operationalize the inclusion of NRS in systematic review s in a more consistent way . The next major step is extending the existing Cochrane Risk of Bias tool so that it can assess the risk of bias to NRS included in a review . Copyright © 2013 John Wiley & Sons , Introduction In 2008 , the UK National Osteoporosis Guideline Group ( NOGG ) produced a guideline on the prevention and treatment of osteoporosis , with an up date in 2013 . This paper presents a major up date of the guideline , the scope of which is to review the assessment and management of osteoporosis and the prevention of fragility fractures in postmenopausal women and men age 50 years or over . Methods Where available , systematic review s , meta-analyses and r and omised controlled trials were used to provide the evidence base . Conclusions and recommendations were systematic ally grade d according to the strength of the available evidence . Results Review of the evidence and recommendations are provided for the diagnosis of osteoporosis , fracture-risk assessment , lifestyle measures and pharmacological interventions , duration and monitoring of bisphosphonate therapy , glucocorticoid-induced osteoporosis , osteoporosis in men , postfracture care and intervention thresholds . Conclusion The guideline , which has received accreditation from the National Institute of Health and Care Excellence ( NICE ) , provides a comprehensive overview of the assessment and management of osteoporosis for all healthcare professionals who are involved in its management Major depression disorder is most commonly treated with antidepressants . However , due to their side effects clinicians seek non-pharmacologic options , and one of these is exercise . The literature on the benefits of exercise for depression is extensive . Nevertheless , two recent review s focusing on antidepressants vs. other therapies as a basis for clinical practice guidelines recommended mainly antidepressants , excluding exercise as a viable choice for treatment of depression . The aim of this perspective is to analyze the literature exploring the reasons for this discrepancy . Two categories of publications were examined : r and omized controlled trials ( RCTs ) and meta-analyses or systematic review s. Based on this re assessment , RCTs comparing exercise to antidepressants reported that exercise and antidepressants were equally effective . RCTs comparing exercise combined with antidepressants to antidepressants only reported a significant improvement in depression following exercise as an adjunctive treatment . Almost all the review s examining exercise vs. other treatments of depression , including antidepressants , support the use of exercise in the treatment of depression , at least as an adjunctive therapy . The two review s examining pharmacologic vs. non-pharmacologic therapies as a basis for clinical practice guidelines examined limited evidence on exercise vs. antidepressants . In addition , it is possible that academics and health care practitioners are skeptical of viewing exercise as medicine . Maybe , there is a reluctance to accept that changes in lifestyle as opposed to pharmacological treatment can alter biological mechanisms . Longitudinal studies are needed for assessing the effectiveness of exercise in real clinical setting s , as well as studies exploring dose-response relationship between exercise and depression Background The purpose of this report is to provide a succinct but comprehensive summary of the scientific evidence regarding the effectiveness of manual treatment for the management of a variety of musculoskeletal and non-musculoskeletal conditions . Methods The conclusions are based on the results of systematic review s of r and omized clinical trials ( RCTs ) , widely accepted and primarily UK and United States evidence -based clinical guidelines , plus the results of all RCTs not yet included in the first three categories . The strength/ quality of the evidence regarding effectiveness was based on an adapted version of the grading system developed by the US Preventive Services Task Force and a study risk of bias assessment tool for the recent RCTs . Results By September 2009 , 26 categories of conditions were located containing RCT evidence for the use of manual therapy :  13 musculoskeletal conditions , four types of chronic headache and nine non-musculoskeletal conditions . We identified 49 recent relevant systematic review s and 16 evidence -based clinical guidelines plus an additional 46 RCTs not yet included in systematic review s and guidelines .Additionally , brief references are made to other effective non-pharmacological , non-invasive physical treatments . Conclusions Spinal manipulation/mobilization is effective in adults for : acute , subacute , and chronic low back pain ; migraine and cervicogenic headache ; cervicogenic dizziness ;  manipulation/mobilization is effective for several extremity joint conditions ; and thoracic manipulation/mobilization is effective for acute/subacute neck pain . The evidence is inconclusive for cervical manipulation/mobilization alone for neck pain of any duration , and for manipulation/mobilization for mid back pain , sciatica , tension-type headache , coccydynia , temporom and ibular joint disorders , fibromyalgia , premenstrual syndrome , and pneumonia in older adults . Spinal manipulation is not effective for asthma and dysmenorrhea when compared to sham manipulation , or for Stage 1 hypertension when added to an antihypertensive diet . In children , the evidence is inconclusive regarding the effectiveness for otitis media and enuresis , and it is not effective for infantile colic and asthma when compared to sham manipulation . Massage is effective in adults for  chronic low back pain and chronic neck pain . The evidence is inconclusive for knee osteoarthritis , fibromyalgia , myofascial pain syndrome , migraine headache , and premenstrual syndrome . In children , the evidence is inconclusive for asthma and infantile colic 2011 ; 14 : 371–380 . 6 . Senn S , Gavini F , Magrez D , Scheen A. Issues in performing a network meta analysis . Statistical Methods in Medical Research 2013 ; 22 : 169–89 . 7 . Salanti G , Higgins JP , Ades A , Ioannidis JP . Evaluation of networks of r and omized trials . Statistical Methods in Medical Research 2008 ; 17 : 279– 301 . 8 . Song F , Clark A , Bachmann MO , Maas J. Simulation evaluation of statistical properties  of methods for indirect and mixed treatment comparisons . BMC Medical Research Methodology 2012 ; 12 : 1–14 . 9 . Jansen JP , Naci H. Is network meta- analysis as valid as st and ard pairwise meta- analysis ? It all depends on the distribution of effect modifers . BMC Medicine 2013 ; 11 : 1 . 10 . The Guidelines Manual . London : National Institute for Health and Clinical Excellence . 2012 . https://www . nice.org.uk/process/pmg6/chapter/6 review ing-the- evidence ( accessed 27/ 05/2017 ) . 11 . Kanters S , Ford N , Druyts E , et al. Use of network meta- analysis  in clinical guidelines . Bulletin of the World Health Organization 2016 ; 94 : 782–4 . 12 . Kiefer C , Sturtz S , Bender R. Indirect comparisons and network meta-analyses : estimation of effects in the absence of head-to-head trials . Deutsches € Arzteblatt International 2015 ; 112 : 803–8 . 13 . Imberger G , Gluud C , Boylan J , Wetterslev J. Systematic review s of anesthesiologic interventions reported as statistically significant : problems with power , precision , and type 1 error protection . Anesthesia and Analgesia 2015 ; 121 : 1611–22 . 14 . Afshari A , Wetterslev J , Smith AF . Can systematic review s with sparse data be trusted ? Anaesthesia 2017 ; 72 : 12–6 . 15 . Jakobsen JC , Wetterslev J , Lange T , Gluud C. Viewpoint : taking into account risks of r and om errors when analysing multiple outcomes in systematic review s. Cochrane Data base of Systematic Review s 2016 ; 3 : ED000111 . 16 . Jakobsen JC , Wetterslev J , Winkel P , Lange T , Gluud C. Thresholds for statistical and clinical significance in systematic review s with meta-analytic methods . BMC Medical Research Methodology 2014 ; 14 : 120 . 17 . Wetterslev J , Jakobsen JC , Gluud C. Trial Sequential Analysis in systematic review s with meta- analysis . BMC Medical Research Methodology 2017 ; 17 : 39 . 18 . Smith AF , Carlisle JC . Review s , systematic review s and Anaesthesia . Anaesthesia 2015 ; 70 : 644–70 . 19 . Cook TM , Kelly FE . The Difficult Airway Society 2015 guidelines and the sacred cows of routine airway management . Anaesthesia 2016 ; 71 : 466–7 . 20 . Schmitz S , Adams R , Walsh C. Incorporating data from various trial design s into a mixed treatment comparison model . Statistics in Medicine 2013 ; 32 : 2935–49 . 21 . Marshall SD , P and it JJ . Radical evolution : the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubation . Anaesthesia 2016 ; 71 : 131–7 . 22 . Black AE , Flynn PE , Smith HL , Thomas ML , Wilkinson KA . Association of Pediatric Anaesthetists of Great Britain and Irel and . Development of a guideline for the management of the unanticipated difficult airway in pediatric practice . Pediatric Anaesthesia 2015 ; 25 : 346–62 . 23 . Hagberg CA , Gabel JC , Connis RT . Difficult Airway Society 2015 guidelines for the management of unanticipated difficult intubation in adults : not just another algorithm . British Journal of Anaesthesia 2015 ; 115 : 812–4 . 24 . Martin-Castro C , Montero A.  Flexible laryngeal mask as an alternative to reinforced tracheal tube for upper chest , head and neck oncoplastic surgery . European Journal of Anaesthesiology 2008 ; 25 : 261–6 . 25 . Maclennan A , Smith AF . An analysis of critical incidents relevant to paediatric anaesthesia reported to the UK National Reporting and Learning System , 2006 - 2008 . Pediatric Anesthesia 2011 ; 21 : 841–7 . 26 . P and it JJ , Popat MT , Cook TM , et al. The Difficult Airway Society ‘ ADEPT ’ Guidance on selecting airway devices : the basis of a strategy for equipment evaluation . Anaesthesia 2011 ; 66 : 726–37 Introduction The extraskeletal role of vitamin D is being increasingly recognised . This has important clinical implication s , as vitamin D deficiency has reached epidemic proportions worldwide . Vitamin D has proposed anti-inflammatory properties , yet the role of vitamin D supplementation in reducing inflammation remains largely unknown . The purpose of this review is to investigate the impact of vitamin D supplementation on inflammation , and to identify relevant knowledge gaps in the field . Methods and analysis Medline , CINAHL , EMBASE and All EBM will be systematic ally search ed for r and omised controlled trials ( RCTs ) and systematic review s of RCTs , comparing vitamin D supplementation with placebo , usual care or other pharmacological or non-pharmacological interventions . One review er will assess articles for eligibility according to prespecified selection criteria , after which 2 independent review ers will perform data extraction and quality appraisal . Meta-analyses will be conducted where appropriate . Ethics and dissemination Formal ethical approval is not required as no primary data is collected . This systematic review will identify potential clinical implication s of vitamin D deficiency and supplementation , and will be disseminated through a peer- review ed publication and at conference meetings , to inform future research on the efficacy of vitamin D supplementation for inflammation and inflammatory diseases . PROSPERO registration number CRD42016037104 Background : Improvements in quality of life ( QoL ) as well as symptomatic relief are important outcomes for the treatment of panic disorder ( PD ) . The aim of this study is to assess the impact of brief cognitive behavior group therapy ( CBGT ) for panic disorder on QoL and to identify the clinical features associated with these changes . Methods : Thirty-six patients with PD refractory to pharmacological treatment took part in a treatment protocol consisting of 12 sessions of CBGT . To evaluate the changes in QoL , the WHOQOL-bref was administered before and after treatment . Results : Thirty-two patients completed the treatment . Significant improvement in all domains of QoL was observed ( p < 0.001 ) , which was associated with reductions in general and anticipatory anxiety ( p = 0.018 ) and agoraphobic avoidance ( p = 0.046 ) . Consistent with previous findings , associations between QoL and panic-free status did not reach significance in this small study ( p = 0.094 ) . Conclusions : CBGT was efficacious in the treatment of PD ; the symptoms of anticipatory anxiety and avoidance appear to be more important than episodic panic episodes in affecting Although pharmacologic treatment remains a critical element in the short- and long-term management of schizophrenia  , the past decade has been a challenging time in terms of real progress . Despite the introduction of several new medications as well as the conduct of larger and more diverse clinical trials , there remains considerable debate as to how far we have progressed in addressing some of the fundamental unmet needs in treating this disorder . A theme in this issue of Schizophrenia Bulletin addresses a number of topics in this context . Although the notion of careful , systematic , and critical summaries of all relevant r and omized controlled trials is not a new one , the Cochrane Schizophrenia Group is relatively young . Clive Adams , one of its founders , and colleagues provide the rationale and history of the group as well as review ing its methods and contributions . The Bulletin also carries a “ Cochrane Corner ” in each issue to alert the field to schizophrenia-related review s. Systematic meta-analyses are playing an increasingly important role in informing both the research agenda and clinical practice . The work of the Cochrane collaboration has been enormously valuable in this process . In recent years , the field of schizophrenia research has benefited from the application of various clinical trial method ologies to enhance the study of treatment outcomes and determine generalizability . Large effectiveness trials have provided data to exp and our knowledge base beyond that which is provided by traditional efficacy trials . Stroup and Geddes provide examples of each type of trial to illustrate their relative advantages and disadvantages . Within the context of different trial design s , Leucht et al provide an overview addressing critical aspects of trial design , potential population sampling bias , endpoint choices and definitions , quality of assessment s , data analysis and reporting , as well as , other potential sources of bias or confounds relevant to the interpretation of clinical trials data in schizophrenia . One of the most difficult challenges in the design , conduct , analysis , and interpretation of clinical trials is the problem of dropouts — those individuals who do not complete the trial , often for unknown reasons . A variety of statistical techniques have been developed and applied in order to address this issue ; however , none is entirely satisfactory . Rabinowitz and Davidov discuss the association of dropout and outcome in trials of antipsychotic medication and its implication s for strategies to address missing data . Another strategy to minimize dropouts in acute treatment trials would be to shorten the length of the trial , particularly when placebo control groups are included . Addressing this issue and drawing on recent meta- analysis suggesting that a substantial proportion of antipsychotic drug response occurs within the first 2 weeks , McMahon and colleagues present an exploratory analysis from short-term placebo controlled clinical trial data suggesting the potential feasibility of reducing the duration of such trials . Much more work needs to be done to determine the benefits and risks of such an approach , but this is a very valuable first step . In the final article , we provide a review of unanswered questions in the pharmacologic treatment of schizophrenia .  Despite numerous trials being conducted with antipsychotic medication , there are many clinical decisions that must be made on a day-to-day basis for which sufficient data are not available to provide an adequate evidence base . We hope that these articles will provide a snapshot of current challenges and opportunities for further progress in the design , conduct , and interpretation of psychopharmacologic trials in schizophrenia Non-response to pharmacotherapy for panic disorder ( PD ) is a well-documented problem . However , little information exists to guide next-step strategies for these non-responders . In addition to pharmacologic augmentation strategies , several studies support the efficacy of cognitive-behavior therapy ( CBT ) for these patients , although data on long-term outcomes has been lacking . In this study , we provide one-year outcomes on a sample of 63 patients who completed group CBT for PD after failing to respond adequately to previous pharmacotherapy . Sustained significant benefit was found for all dimensional outcome scores , and nearly two-thirds of the sample met remission criteria . This occurred with reductions in medication use over the follow-up period . Negative predictors of remission status included comorbid dysthymia , social phobia , and generalized anxiety disorder . These results provide additional evidence for the efficacy of CBT for medication non-responders with PD An influential review in 2010 concluded that non-pharmacological multi-component interventions have positive effects on cognitive functioning , activities of daily living , behaviour and mood of people with dementia . Our aim here is to provide an up-to- date overview of research into psychosocial interventions and their impact on psychosocial outcomes . We focused on r and omised controlled trials , controlled studies and review s published between October 2008 and August 2015 , since the earlier review . The search of PsychInfo , Medline and the Cochrane data base of systematic review s yielded 61 relevant articles , organised into four themes echoing key phases of the care pathway : Living at home with dementia ( five review s , eight studies ) , carer interventions ( three review s , four studies ) , interventions in residential care ( 16 review s , 12 studies ) and end-of-life care ( three review s , two studies ) , along with an additional group spanning community and institutional setting s ( six review s , two studies ) . Community findings suggested that appointment of dementia specialists and attention to case management can produce positive outcomes ;  physical therapies , cognitive training and modified cognitive behaviour therapy also had a range of benefits . There was more limited evidence of positive benefits for people with dementia through interventions with family carers . Thirty-two articles focused on the management of ‘ behavioural symptoms ’ through a range of interventions all of which had some evidence of benefit . Also a range of multi-component and specific interventions had benefits for cognitive , emotional and behavioural well-being of people with dementia in residential setting s , as well as for quality of life . Overall , interventions tended to be short term with impact only measured in the short term . We recommend further research on interventions to promote living well in the community post-diagnosis and to address end-of-life care . Development of psychosocial interventions would benefit from moving beyond the focus on control of behaviours to focus on wider aspects of life for people with dementia Objective To assess , in a sample of systematic review s of non-pharmacological interventions , the completeness of intervention reporting , identify the most frequently missing elements , and assess review authors ’ use of and beliefs about providing intervention information . Design Analysis of a r and om sample of systematic review s of non-pharmacological stroke interventions ; online survey of review authors . Data sources and study selection The Cochrane Library and PubMed were search ed for potentially eligible systematic review s and a r and om sample of these assessed for eligibility until 60 ( 30 Cochrane , 30 non-Cochrane ) eligible review s were identified . Data collection In each review , the completeness of the intervention description in each eligible trial ( n=568 ) was assessed by 2 independent raters using the Template for Intervention Description and Replication ( TIDieR ) checklist . All review authors ( n=46 ) were invited to complete a survey . Results Most review s were missing intervention information for the majority of items . The most incompletely described items were : modifications , fidelity , material s , procedure and tailoring ( missing from all interventions in 97 % , 90 % , 88 % , 83 % and 83 % of review s , respectively ) . Items that scored better , but were still incomplete for the majority of review s , were : ‘ when and how much ’ ( in 31 % of review s , adequate for all trials ; in 57 % of review s , adequate for some trials ) ; intervention mode ( in 22 % of review s , adequate for all trials ; in 38 % , adequate for some trials ) ; and location ( in 19 % of review s , adequate for all trials ) . Of the 33 ( 71 % ) authors who responded , 58 % reported having further intervention information but not including it , and 70 % tried to obtain information . Conclusions Most focus on intervention reporting has been directed at trials . Poor intervention reporting in stroke systematic review s is prevalent , compounded by poor trial reporting . Without adequate intervention descriptions , the conduct , usability and interpretation of review s are restricted and therefore , require action by trialists , systematic review ers , peer review ers and editors Objective ( i ) to determine the outcomes of whole-body vibration training ( WBVT ) on obese individuals , and the intervention setting s producing such effects ; ( ii ) identify potential improper or harmful use of WBVT . Design Systematic review . Data sources Medline , Scopus , Web of Science , PEDro and Scielo until July 2018 . Eligibility criteria Full papers evaluating the effect of  WBVT on body composition , cardiovascular status and functional performance in obese adults . Papers with PEDro score<4 were excluded . Study appraisal and synthesis Risk of bias and quality of WBVT reporting were assessed with PEDro scale ( r and omized controlled trials ) or TREND checklist ( non-r and omized studies ) and a 14-items checklist , respectively . Weighted acceleration , daily exposure and Hedges ’ adjusted g were computed . Results We included 18 papers published 2010–2017 . Typical interventions consisted in three sessions/week of exercises ( squats , calf-raises ) performed on platforms vibrating at 25–40 Hz ( amplitude : 1–2 mm ) ; according to ISO 2631–1:1997 , daily exposure was “ unsafe ” in 7/18 studies . Interventions lasting ≥6 weeks improved cardiac autonomic function and reduced central /peripheral arterial stiffness in obese women ; 10 weeks of WBVT  produced significant weight/fat mass reduction , leg strength improvements as resistance training , and enhanced glucose regulation when added to hypocaloric diet . No paper evidence d losses of lean mass . Isolated cases of adverse effects were reported . Summary To date , WBVT is a promising adjuvant intervention therapy for obese women ; long-term studies involving larger cohorts and male participants are required to demonstrate the associated safety and health benefits . The therapeutic use of WBVT in the management of obese patients is still not st and ardised and should be supported by an extensive knowledge on the causality between vibration parameters and outcomes Background Multiple treatments are frequently available for a given condition , and clinicians and patients need a comprehensive , up-to- date synthesis of evidence for all competing treatments . We aim ed to quantify the waste of research related to the failure of systematic review s to provide a complete and up-to- date evidence synthesis over time . Methods We performed a series of systematic overviews and networks of r and omized trials assessing the gap between evidence covered by systematic review s and available trials of second-line treatments for advanced non-small cell lung cancer . We search ed the Cochrane Data base of Systematic Review s , Data base of Abstract s of Review s of Effects , MEDLINE , EMBASE , and other re sources sequentially by year from 2009 to March 2 , 2015 . We sequentially compared the amount of evidence missing from systematic review s to the r and omized evidence available for inclusion each year . We constructed cumulative networks of r and omized evidence over time and evaluated the proportion of trials , patients , treatments , and treatment comparisons not covered by systematic review s on December 31 each year from 2009 to 2015 . Results We identified 77 trials ( 28,636 patients ) assessing 47 treatments with 54 comparisons and 29 systematic review s ( 13 published after 2013 ) . From 2009 to 2015 , the evidence covered by existing systematic review s was consistently incomplete : 45 % to 70 % of trials ; 30 % to 58 % of patients ; 40 % to 66 % of treatments ; and 38 % to 71 % of comparisons were missing . In the cumulative networks of r and omized evidence , 10 % to 17 % of treatment comparisons were partially covered by systematic review s and 55 % to 85 % were partially or not covered . Conclusions We illustrate how systematic review s of a given condition provide a fragmented , out-of- date panorama of the evidence for all treatments . This waste of research might be reduced by the development of live cumulative network meta-analyses At an orthodontic meeting in recent years , a colleague recounted to me that when a presenter had finished their presentation on a systematic review , the person beside leaned over and said to my colleague ‘ not another systematic review where it ’s not possible to draw any firm conclusions ’ . So an element of frustration was clear based on the screening of a large volume of evidence to arrive at such a low point for a conclusion . This , however , is now a familiar outcome for many orthodontic systematic review s. In this short editorial , I have attempted to give a brief outline of the proposed benefits of systematic review s but more importantly , to highlight , some issues we all need to bear in mind in their regard . The increasing focus on evidence -based healthcare , including orthodontics , has shunned the narrative review and spawned the systematic review . Aim ing to identify , evaluate and summarize the findings of all relevant studies on a specific topic , its exacting systematic approach should minimize bias and provide conclusions based on reliable findings . Meta-analyses of r and omized clinical trials with low risk of bias are considered the highest level of evidence available for evaluating the effects of an intervention . Systematic review s are also important tools in setting the research agenda via their recommendations for future research and authors can alert research ers to the most pertinent outcomes in clinical practice . But systematic review s like any other study type are not without their variability , both in dentistry in general and specifically in orthodontics . Large differences have also been observed in the quality of reporting of several characteristics between Cochrane and non-Cochrane systematic review s. A key question that must be asked when looking at all Cochrane review s is whether the review has been undertaken in a way to avoid bias and whether the data and results from the included studies are valid . Conclusions may be distorted if bias is introduced to the review process at any stage . For example , incomplete search ing for all relevant studies may lead to publication bias ; there is strong association between publication and studies reporting significant or positive findings in medicine and also within orthodontics . With regard to studies included within the review , these need to be assessed to ensure that they are undertaken and reported in a manner that is free of bias ( systematic error ) . Outcome reporting bias ( ORB ) may also be relevant , e.g. in a study identified as relevant to a review , where data exist on the outcome of interest but only selected findings have been given based on the results . Although systematic review s have emphasized ‘ assessment of method ological quality ’ of included studies , the Cochrane h and book recommends a focus on ‘ risk of bias assessment ’ instead . The justifications are four-fold : it targets whether the results of included studies should be credible ; despite being carried out to the highest st and ards , a study may have risk of bias due to , e.g. impracticality/impossibility of blinding of participants / study personnel ; some quality markers , e.g. a power calculation is unlikely to directly affect risk of bias ; it overcomes ambiguity between quality of reporting and quality of the underlying research Objectives To up date our previous evaluation of the exercise interventions used in r and omised controlled trials of breast cancer survivors in relation to ( 1 ) the application of the principles of exercise training in the exercise prescription ; ( 2 ) the reporting of the components of the exercise prescription ; and ( 3 ) the reporting of adherence of participants to the prescribed interventions . Design Systematic review . Data sources The OVID Medline , Embase , CINAHL and SPORTD iscus electronic data bases were search ed from January 2010 to January 2017 . Eligibility criteria R and omised controlled trials of at least 4 weeks of aerobic and /or resistance exercise in women diagnosed with breast cancer , reporting on physical fitness or body composition outcomes .  Results Specificity was appropriately applied by 84 % , progression by 29 % , overload by 38 % and initial values by 67 % of newly identified studies . Reversibility was reported by 3 % and diminishing returns by 22 % of newly identified studies . No studies reported all components of the exercise prescription in the methods , or adherence to the prescribed intervention in the results . Reporting of reversibility has increased from 2010 , but no other improvements in reporting were noted from the previous review . Summary / Conclusion No studies of exercise in women with breast cancer attended to all principles of exercise training , or reported all components of the exercise prescription  in the methods , or adherence to the prescription in the results . Full reporting of the exercise prescribed and completed is essential for study replication in research and translating research findings into the community , and should be prioritised in future trials Bipolar disorder ( BPD ) has received increasing attention from public and professional sources . Although pharmacologic treatments are considered the sine qua non in the treatment of youth with BPD , psychosocial interventions are critical to assist the child and family cope with symptoms that carry with them significant morbidity and mortality . Treatments developed to date are few in number ; all are psychoeducationally based , using cognitive-behavioral and family systems interventions within a biopsychosocial framework . This paper review s possible mediators of outcome , including caregiver concordance , children 's social skills , hopelessness , and family stress . The author has developed two family-based psychoeducational interventions for the treatment of youth with BPD : multifamily psychoeducation groups ( MFPG ) and individual family psychoeducation ( IFP ) . These treatments are both described and the results from a previously published r and omized clinical trial ( RCT ) of MFPG are summarized . Then , new findings from an RCT of IFP are presented , along with preliminary pilot data from an exp and ed version of IFP . The paper concludes with recommendations for future research Background The quality of reporting of harms data in r and omised controlled trials ( RCTs ) has been reported to be suboptimal . Rheumatoid arthritis ( RA ) has seen a massive growth in novel pharmacotherapies in the last decade . Objective The aim of this study was to assess the quality of reporting of harms-related data  in RCTs evaluating pharmacological interventions for RA according to the CONSORT ( Consoli date d St and ards of Reporting Trials ) statement on harms reporting extension . Study selection RCTs published between January 2011 and August 2016 in the five highest impact factor journals in general medicine and two in rheumatology subject categories as per 2015 Journal Citation Reports were included . Reports of secondary , supplementary or exploratory analyses of RCTs and non-inferiority trials were excluded . Two review ers independently extracted data using a structured , pilot-tested , 18-item question naire developed based on CONSORT harms extension recommendations . Findings 68 RCTs were included in the review . Out of a maximum harms reporting score of 18 , the mean ( SD ) score was 8.51 ( 3.5 ) ( range=0–15 ) . More than half ( 56.5 % ) of the RCTs reported ≤50 % of items and only three ( 4.3 % ) RCTs reported more than 70 % ( score ≥14 ) of the items . Multilinear regression analyses found that region of trial origin ( p=0.01 ) , sample size ( p=0.001 ) and whether the study was a long-term extension of a trial or not ( p=0.04 ) were independent predictors associated with higher total harms reporting score . Conclusions The adherence to CONSORT harms extension was poor in recently published RCTs of pharmacological interventions for RA . There is a need to improve quality of harms reporting in RCTs to allow transparent and balanced assessment of the benefit-risk ratio in clinical decision making OBJECTIVES To review the accuracy of diagnoses of chronic obstructive pulmonary disease ( COPD ) in primary care in Australia , and to describe smokers ' experiences with and preferences for smoking cessation . DESIGN , SETTING AND PARTICIPANTS Patients were invited to participate if they were at least 40 years old and had visited participating general practice clinics in Melbourne at least twice during the previous 12 months , reported being current or ex-smokers with a smoking history of at least 10 pack-years , or were being managed for COPD . Interviews based on a structured question naire and case finding ( FEV1/FEV6 measurement ) were followed , when appropriate , by  spirometry testing  and assessment of health-related quality of life , dyspnoea and symptoms . RESULTS 1050 patients attended baseline interviews ( February 2015 - April 2017 ) at 41 practice s. Of 245 participants managed for COPD , 130 ( 53.1 % ) met the spirometry-based definition ( post-bronchodilator FEV1/FVC < 0.7 ) or had a clinical correlation ; in 37 % of cases COPD was not confirmed , and no definitive result was obtained for 9.8 % of patients . Case finding and subsequent spirometry testing identified 142 new COPD cases ( 17.6 % of participants without prior diagnosis ; 95 % CI , 15.1 - 20.5 % ) . 690 participants ( 65.7 % ) were current smokers , of whom 360 had attempted quitting during the previous 12 months ; 286 ( 81.0 % of those attempting to quit ) reported difficulties during previous quit attempts . Nicotine replacement therapy ( 205 , 57.4 % ) and varenicline ( 110 , 30.8 % ) were the most frequently employed pharmacological treatments ; side effects were common . Hypnotherapy was the most popular non-pharmacological option ( 62 smokers , 17 % ) ; e-cigarettes were tried by 38 ( 11 % ) . 187 current smokers ( 27.6 % ) would consider using e-cigarettes in future attempts to quit . CONCLUSIONS COPD was both misdiagnosed and missed . Case finding and effective use of spirometry testing could improve diagnosis . Side effects of smoking cessation medications and difficulties during attempts to quit smoking are common . Health professionals should emphasise evidence -based treatments , and closely monitor quitting difficulties and side effects of cessation aids . TRIAL REGISTRATION Australian New Zeal and Clinical Trials Registry ACTRN12614001155684
Quetiapine extended-release augmentation has not been found to be beneficial , in comparison to placebo , in non-responders to previously recommended pharmacotherapy .
In non-responders to cognitive behavioral therapy ( CBT ) , switching to paroxetine/citalopram has been found to be more effective than continuing CBT .
Acceptance and commitment therapy ( ACT ) has shown some improvement in patients ’ resistance to previous psychological/pharmacological interventions compared with a waiting-list condition .
Prolonged pharmacotherapy may produce significant improvement in patients with unsatisfactory response to short-term pharmacotherapy  , while switching to pharmacotherapy may help non-responders to CBT .
Purpose of Review Purpose of Review Management of treatment-resistant ( TR ) panic disorder ( PD ) is an unresolved issue .
In this paper , we provide a brief summary of previous findings , an up date d ( 2015–2017 ) systematic review of pharmacological/non-pharmacological studies , and our personal perspective on this topic .