Checklists to prevent diagnostic errors: a pilot randomized controlled trial Bias due to selective inclusion and reporting of outcomes and analyses in systematic reviews of randomised trials of healthcare interventions. Distinguishing patients with chronic fatigue from those with chronic fatigue syndrome: a diagnostic study in UK primary care. Dyspepsia Management in Primary Care in The Netherlands: To What Extent Is Helicobacter pylori Diagnosis and Treatment Incorporated? Characteristics and predictors of frequent utilization of emergency services. How to write an evidence-based clinical review article. The Effectiveness of Psychosocial Interventions as Adjuncts to Orthopaedic Surgery: A Systematic Review Protocol Self-reported psychosocial needs and health-related quality of life of colorectal cancer survivors. Evaluating the complaint of fatigue in primary care: diagnoses and outcomes. Enabling the diagnosis of occult psychiatric illness in the emergency department: a randomized, controlled trial of the computerized, self-administered PRIME-MD diagnostic system. Chief complaint of fatigue: a prospective study. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society Psychosocial effects of workplace exercise - A systematic review. The impact of outcome reporting bias in randomised controlled trials on a cohort of systematic reviews Design of a multicentre randomized controlled trial to evaluate the effectiveness of a tailored clinical support intervention to enhance return to work for gastrointestinal cancer patients A qualitative study to explore the concept of fatigue/tiredness in cancer patients and in healthy individuals. Patients' perceptions of fatigue in rheumatoid arthritis: overwhelming, uncontrollable, ignored. Single photon emission computed tomography for the diagnosis of coronary artery disease: an evidence-based analysis. Community-based care for the management of type 2 diabetes: an evidence-based analysis. Reporting of prognostic markers: current problems and development of guidelines for evidence-based practice in the future Electronic Laboratory Medicine ordering with evidence-based Order sets in primary care (ELMO study): protocol for a cluster randomised trial Chief complaint fatigue: a longitudinal study from the patient's perspective. A conversation with Joseph Lau.
Abstract Background : Many diagnostic errors are caused by premature closure of the diagnostic process . To help prevent premature closure , we developed checklists that prompt physicians to consider all reasonable diagnoses for symptoms that commonly present in primary care . Methods : We enrolled 14 primary care physicians and 100 patients in a r and omized clinical trial . The study took place in an emergency department ( 5 physicians ) and a same-day access clinic ( 9 physicians ) . The physicians were r and omized to usual care vs. diagnostic checklist . After completing the history and physical exam , checklist physicians read aloud a differential diagnosis checklist for the chief complaint . The primary outcome was diagnostic error , which was defined as a discrepancy between the diagnosis documented at the acute visit and the diagnosis based on a 1-month follow-up phone call and record review . Results : There were 17 diagnostic errors . The mean error rate among the seven checklist physicians was not significantly different from the rate among the seven usual-care physicians ( 11.2 % vs. 17.8 % ; p=0.46 ) . In a post-hoc subgroup analysis , emergency physicians in the checklist group had a lower mean error rate than emergency physicians in the usual-care group ( 19.1 % vs. 45.0 % ; p=0.04 ) . Checklist physicians considered more diagnoses than usual-care physicians during the patient encounters ( 6.5 diagnoses [ SD 4.2 ] vs. 3.4 diagnoses [ SD 2.0 ] , p<0.001 ) . Conclusions : Checklists did not improve the diagnostic error rate in this study . However further development and testing of checklists in larger studies may be warranted BACKGROUND Systematic review s may be compromised by selective inclusion and reporting of outcomes and analyses . Selective inclusion occurs when there are multiple effect estimates in a trial report that could be included in a particular meta- analysis ( e.g. from multiple measurement scales and time points ) and the choice of effect estimate to include in the meta- analysis is based on the results ( e.g. statistical significance , magnitude or direction of effect ) . Selective reporting occurs when the reporting of a subset of outcomes and analyses in the systematic review is based on the results ( e.g. a protocol -defined outcome is omitted from the published systematic review ) . OBJECTIVES To summarise the characteristics and synthesis e the results of empirical studies that have investigated the prevalence of selective inclusion or reporting in systematic review s of r and omised controlled trials ( RCTs ) , investigated the factors ( e.g. statistical significance or direction of effect ) associated with the prevalence and quantified the bias . SEARCH METHODS We search ed the Cochrane Methodology Register ( to July 2012 ) , Ovid MEDLINE , Ovid EMBASE , Ovid PsycINFO and ISI Web of Science ( each up to May 2013 ) , and the US Agency for Healthcare Research and Quality ( AHRQ ) Effective Healthcare Program 's Scientific Re source Center ( SRC ) Methods Library ( to June 2013 ) . We also search ed the abstract books of the 2011 and 2012 Cochrane Colloquia and the article alerts for method ological work in research synthesis published from 2009 to 2011 and compiled in Research Synthesis Methods . SELECTION CRITERIA We included both published and unpublished empirical studies that investigated the prevalence and factors associated with selective inclusion or reporting , or both , in systematic review s of RCTs of healthcare interventions . We included empirical studies assessing any type of selective inclusion or reporting , such as investigations of how frequently RCT outcome data is selectively included in systematic review s based on the results , outcomes and analyses are discrepant between protocol and published review or non-significant outcomes are partially reported in the full text or summary within systematic review s. DATA COLLECTION AND ANALYSIS Two review authors independently selected empirical studies for inclusion , extracted the data and performed a risk of bias assessment . A third review author resolved any disagreements about inclusion or exclusion of empirical studies , data extraction and risk of bias . We contacted authors of included studies for additional unpublished data . Primary outcomes included overall prevalence of selective inclusion or reporting , association between selective inclusion or reporting and the statistical significance of the effect estimate , and association between selective inclusion or reporting and the direction of the effect estimate . We combined prevalence estimates and risk ratios ( RRs ) using a r and om-effects meta- analysis model . MAIN RESULTS Seven studies met the inclusion criteria . No studies had investigated selective inclusion of results in systematic review s , or discrepancies in outcomes and analyses between systematic review registry entries and published systematic review s. Based on a meta- analysis of four studies ( including 485 Cochrane Review s ) , 38 % ( 95 % confidence interval ( CI ) 23 % to 54 % ) of systematic review s added , omitted , up grade d or down grade d at least one outcome between the protocol and published systematic review . The association between statistical significance and discrepant outcome reporting between protocol and published systematic review was uncertain . The meta-analytic estimate suggested an increased risk of adding or upgrading ( i.e. changing a secondary outcome to primary ) when the outcome was statistically significant , although the 95 % CI included no association and a decreased risk as plausible estimates ( RR 1.43 , 95 % CI 0.71 to 2.85 ; two studies , n = 552 meta-analyses ) . Also , the meta-analytic estimate suggested an increased risk of downgrading ( i.e. changing a primary outcome to secondary ) when the outcome was statistically significant , although the 95 % CI included no association and a decreased risk as plausible estimates ( RR 1.26 , 95 % CI 0.60 to 2.62 ; two studies , n = 484 meta-analyses ) . None of the included studies had investigated whether the association between statistical significance and adding , upgrading or downgrading of outcomes was modified by the type of comparison , direction of effect or type of outcome ; or whether there is an association between direction of the effect estimate and discrepant outcome reporting . Several secondary outcomes were reported in the included studies . Two studies found that reasons for discrepant outcome reporting were infrequently reported in published systematic review s ( 6 % in one study and 22 % in the other ) . One study ( including 62 Cochrane Review s ) found that 32 % ( 95 % CI 21 % to 45 % ) of systematic review s did not report all primary outcomes in the abstract . Another study ( including 64 Cochrane and 118 non-Cochrane review s ) found that statistically significant primary outcomes were more likely to be completely reported in the systematic review abstract than non-significant primary outcomes ( RR 2.66 , 95 % CI 1.81 to 3.90 ) . None of the studies included systematic review s published after 2009 when reporting st and ards for systematic review s ( Preferred Reporting Items for Systematic review s and Meta-Analyses ( PRISMA ) Statement , and Method ological Expectations of Cochrane Intervention Review s ( MECIR ) ) were disseminated , so the results might not be generalisable to more recent systematic review s. AUTHORS ' CONCLUSIONS Discrepant outcome reporting between the protocol and published systematic review is fairly common , although the association between statistical significance and discrepant outcome reporting is uncertain . Complete reporting of outcomes in systematic review abstract s is associated with statistical significance of the results for those outcomes . Systematic review outcomes and analysis plans should be specified prior to seeing the results of included studies to minimise post-hoc decisions that may be based on the observed results . Modifications that occur once the review has commenced , along with their justification , should be clearly reported . Effect estimates and CIs should be reported for all systematic review outcomes regardless of the results . The lack of research on selective inclusion of results in systematic review s needs to be addressed and studies that avoid the method ological weaknesses of existing research are also needed BACKGROUND Chronic fatigue syndrome ( CFS ) has been defined , but many more patients consult in primary care with chronic fatigue that does not meet the criteria for CFS . General practitioners ( GPs ) do not generally use the CFS diagnosis , and have some doubt about the validity of CFS as an illness . AIM To describe the proportion of patients consulting their GP for fatigue that met the criteria for CFS , and to describe the social , psychological , and physical differences between patients with CFS and those with non-CFS chronic fatigue in primary care . DESIGN OF STUDY Baseline data from a trial of complex interventions for fatigue in primary care . SETTING Twenty-two general practice s located in London and the South Thames region of the United Kingdom recruited patients to the study between 1999 and 2001 . METHOD One hundred and forty-one patients who presented to their GP with unexplained fatigue lasting six months or more as a main symptom were recruited , and the Centers for Disease Control ( CDC ) case definition was applied to classify CFS . RESULTS Approximately two-thirds ( 69 % ) of patients had chronic fatigue  and not CFS . The duration of fatigue ( 32 months ) and perceived control over fatigue were similar between groups ; however , fatigue , functioning , associated symptoms , and psychological distress were more severe in the patients in the CFS group , who also consulted their GP significantly more frequently , were twice as likely to be depressed , and more than twice as likely to be unemployed . About half ( CFS = 50 % ; chronic fatigue = 55 % ) in each group attributed their fatigue to mainly psychological causes . CONCLUSIONS In primary care , CFS is a more severe illness than chronic fatigue , but non-CFS chronic fatigue is associated with significant fatigue and is reported at least twice as often . That half of patients , irrespective of CFS status , attribute their fatigue to psychological causes , more than is observed in secondary care , indicates an openness to the psychological therapies provided in that setting . More evidence on the natural history of chronic fatigue and CFS in primary care is required , as are trials of complex interventions . The results may help determine the usefulness of differentiating between chronic fatigue and CFS Background : Many guidelines on the management of Helicobacter pylori (HP)-related dyspepsia have been launched over the past decade . The suggested policies in these guidelines are often more consensus- than evidence -based ( test- and -treat policy , test and endoscope ) , which may cause confusion among primary -care physicians . Aim : To determine the current management of HP-related dyspepsia by Dutch general practitioners ( GPs ) . Methods : A r and om sample of 5 % of all Dutch GPs ( n = 355 ) were sent a question naire on the diagnosis and treatment of HP infections in dyspepsia management . Results : The response rate was 66.2 % ( n = 235 ) . Almost 80 % of the responding GPs stated they had conducted HP testing ( via endoscopy or serology ) during the previous 12 months . In the same time period , more than 94 % had actually prescribed a HP eradication therapy . A total of 70 % of the GPs stated that they used  endoscopy  to  test for HP infection  , 54 % used  serology ( ELISA ) ; whole-blood tests and carbon urea breath tests  were not used . Patients with a history of peptic ulcer disease , those on chronic acid-suppressive drugs and patients with recurrent ulcer-like complaints were most frequently tested for HP infection . Conclusions : Given the frequency of consultations for dyspepsia in primary care in the Netherl and s ( 150 new dyspeptic patients per average practice per year ) , and the reported average number of HP tests perfomed ( 1–5 per GP per year ) , HP diagnosis plays a modest role in the management of dyspepsia in Dutch general practice s. Neither the ‘ test- and -treat ’ policy recommended in the Maastricht guidelines , nor its advice regarding the choice of diagnostic tests ( carbon urea breath test or serology ) , is being followed . The majority of GPs uses endoscopy for the detection of HP infection INTRODUCTION Although frequent ED users account for a small percentage of ED visits , these patients can drain the system , contributing to overcrowding and lowered quality of care . METHODS This retrospective descriptive correlational study explored characteristics of  frequent ED users at a large Midwestern urban hospital and factors predictive of high ED utilization . The sample included adult patients with at least 6 visits in 2005 - 2006 ( N = 201 ) . For each , 6 visits were r and omly chosen for chart review ( N = 1200 visits ) of demographic , health history , and clinical factors such as chief complaints . RESULTS Frequent users were commonly female , 35 years old , white , single , unemployed , living alone , with private insurance/Medicaid and a primary care physician . Top chief complaints were abdominal pain , headache , chest pain , low back pain , and lower extremity pain . However , a Poisson regression found that the following characteristics were associated with a higher number of ED visits : male , non-Black race , part-time employment , retired/unemployed , having Medicare , and having a chief complaint of upper respiratory infection . Headache approached significance as an independent predictor of more visits . DISCUSSION Almost 95 % had fewer than 10 ED visits per year , with pain the overall top chief complaint . Seventy percent of frequent visits occurred during either the evening or night shift , perhaps indicating access issues to primary physicians or urgent care clinics . The rate of frequent users was comparable with other investigations , yet few similarities in patient characteristics and predictors of high ED utilization were found , partly because of the retrospective design , but certainly reinforcing limited generalizability of ED utilization patterns across centers in different metropolitan and geographic regions Traditional clinical review articles , also known as up date s , differ from systematic review s and meta-analyses . Up date s selectively review the medical literature while discussing a topic broadly . Non-quantitative systematic review s comprehensively examine the medical literature , seeking to identify and synthesize all relevant information to formulate the best approach to diagnosis or treatment . Meta-analyses ( quantitative systematic review s ) seek to answer a focused clinical question , using rigorous statistical analysis of pooled research studies . This article presents guidelines for writing an evidence -based clinical review article for American Family Physician . First , the topic should be of common interest and relevance to family practice . Include a table of the continuing medical education objectives of the review . State how the literature search was done and include several sources of evidence -based review s , such as the Cochrane Collaboration , BMJ 's Clinical Evidence , or the InfoRetriever Web site . Where possible , use evidence based on clinical outcomes relating to morbidity , mortality , or quality of life , and studies of primary care population s. In articles su bmi tted to American Family Physician , rate the level of evidence for key recommendations according to the following scale : level A ( r and omized controlled trial [ RCT ] , meta- analysis ) ; level B ( other evidence ) ; level C ( consensus/expert opinion ) . Finally , provide a table of key summary points AIMS Pain and anxiety are commonly reported among those undergoing orthopaedic surgery . Improvement in anxiety and pain control might be achieved by supplementing st and ard care with psychological interventions . However , the effectiveness of adjunctive psychosocial interventions in anxiety and pain control have not been addressed sufficiently by previous systematic review s in orthopaedic surgeries . The present study aim ed to assess the effectiveness of adjunctive psychosocial techniques to improve perioperative clinical care in orthopaedic surgery , to identify the most effective intervention types and to evaluate potential moderators . METHODS We will perform a systematic review and meta- analysis to address the study aims . PubMed , PsycINFO , CINAHL and ProQuest Dissertations & Theses will be search ed between 1980 and 2015 . Prospect i ve controlled clinical trials completed in adults , contrasting st and ard care and st and ard care supplemented with psychosocial methods  , will be eligible for inclusion . Effectiveness will be assessed through the outcomes of postoperative pain intensity , analgesic requirement , perioperative anxiety , quality of life and postoperative recovery . The results of a r and om-effect meta- analysis will be reported . To aid implementation of best practice , moderating effects of the type and timing of psychosocial intervention , type of surgical intervention and type of anaesthesia will be evaluated through meta-regression . Sensitivity analyses and subgroup contrasts will follow as necessary . DISCUSSION Recommendations will be made to improve medical care in orthopaedic procedures . The quality of evidence will be rated using GRADE criteria . Copyright © 2016 John Wiley & Sons , PURPOSE OF THE RESEARCH To investigate the prevalence and nature of unmet needs among colorectal cancer ( CRC ) survivors and the relationship between needs and quality of life ( QoL ) . METHODS AND SAMPLE Using the Northern Irel and Cancer Registry ( NICR ) as a sampling frame and working in collaboration with primary care physicians or GPs , the Cancer Survivors Unmet Needs ( CaSUN ) question naire and the Quality of Life in Adult Cancer Survivors Scale ( QLACS ) were posted to a r and omly selected sample of 600 CRC survivors . KEY RESULTS Approximately 69 % ( 413/600 ) met eligibility criteria for participating in the study ; and 30 % ( 124/413 ) responded to the survey . A comparative analysis of NICR data between respondents and non-respondents did not indicate any systematic bias except that respondents appeared to be younger ( 65 years vs. 67 years ) . Approximately 60 % of respondents reported having no unmet needs , with 40 % reporting one or more unmet health and social care needs such as fear of recurrence , information needs , difficulty obtaining travel insurance and car parking problems . QoL was significantly lower for CRC survivors who reported an unmet need . Highest scores ( poorer QoL ) were reported for fatigue , welfare benefits and distress recurrence . CONCLUSIONS Overall , the majority of CRC survivors who had care needs appeared to have needs that were mainly psychosocial in nature and these unmet needs were related to poorer PURPOSE This case series describes associated diagnoses and prognoses of persistent fatigue in a community-based , primary care population . PATIENTS AND METHODS All patients presenting to a private practice internist with a chief complaint of fatigue of more than 1 month 's duration were prospect ively evaluated with clinical ly directed examination and diagnostic testing .  Patients were excluded if they had a previously diagnosed illness associated with fatigue . Fatigue was attributed to newly established diagnoses or medication use based on explicit criteria . Change in the state of each patient 's fatigue was measured 6 months after entry . RESULTS Fifty-two consecutive patients entered the study . The diagnoses associated with fatigue were a medical disorder in 25 patients , depression in 10 patients , and no definitive diagnosis in 18 patients . The mean cost of diagnostic testing was $ 131 . At 6 months , 37 of 52 patients ( 72 % ) reported improvement in or resolution of their fatigue . CONCLUSION In a primary care setting , many patients presenting with persistent fatigue have an associated , treatable disease that can be determined using a cost-effective , clinical ly directed approach . Most will experience an improvement in their fatigue STUDY OBJECTIVE Undiagnosed mental illness is highly prevalent and produces needless morbidity . Emergency department patients with vague or longst and ing complaints are at risk for occult mental illness , but are seldom diagnosed . We conducted this study to determine whether a previously vali date d , self-administered , computerized psychiatric interview ( Primary Care Evaluation of Mental Disorders [ PRIME-MD ] ) could increase the detection of occult psychiatric illness in the ED . METHODS This was a r and omized , controlled trial of consecutive patients enrolled during convenient times at a university teaching hospital ED with an annual census of 38,000 . ED house staff and attending physicians participated . Patients were those with nonspecific complaints potentially associated with occult psychiatric illness ( eg , long-st and ing headache , abdominal or back pain ) . Exclusion criteria were known psychiatric illness , complaint , or medication ; and straightforward reason for the ED visit . Consenting subjects completed the PRIME-MD question naire in the waiting room , and were r and omly assigned to either the " report " ( report results given to physician ) or " no-report " groups . PRIME-MD results were clipped to the front of the chart of report group patients . There was no other intervention . The main outcome measures were the percentage of all patients and percentage of patients with a PRIME-MD diagnosis who received a psychiatric diagnosis , consultation , or referral from the emergency physician . RESULTS A total of 339 ( 5.1 % ) of all patients were approached ; 230 consented to participate in the study , and 218 completed the PRIME-MD session and were r and omly assigned to study groups . Ninety-two patients in the report group and 98 cases in the no-report group were analyzed . Patients were omitted for the following reasons : left without being seen ( 8) , mistakenly enrolled ( 10 ) , or unretrievable medical records ( 10 ) . Seventy-nine ( 42 % ) patients received a psychiatric diagnosis from PRIME-MD and 9 ( 5 % ) from the physician . The frequencies of physician psychiatric diagnosis and referral did not differ between groups ( diagnosis : report 9 % , no report 9 % , Delta 0 % , 95 % confidence interval [ CI ] -13 , 14 ; referral : report 9 % , no report 7 % , Delta 2 % , 95 % CI -11 , 16 ) . CONCLUSION ED patients willingly completed the PRIME-MD question naire ( in a median time of 7 minutes ) , which frequently diagnosed psychiatric conditions . Despite this , physicians rarely diagnosed or treated these conditions regardless of whether they were provided with the PRIME-MD diagnoses The Dartmouth COOP Project , a primary care research network , conducted a prospect i ve study of patients presenting to 28 primary care practice s with a chief complaint of fatigue . Data were gathered on fatigue status , associated systems , health status , and origin of fatigue .  Fatigue patients were demographically similar to nonfatigue patients but had significantly worse physical and mental health at study intake . Sixty-three percent of physicians and 52 % of patients rated fatigue origin as primarily physical ( gamma = 0.48 , P less than .05 ) , but in 41 % of cases , physicians indicated there was substantial interaction between physical and psychological factors . Only two factors -- depression and anxiety -- separated fatigue of physical origin from fatigue of psychological origin . Clinicians must thoughtfully evaluate fatigue 's often multiple causes and communicate their underst and ing of those causes to the patient to gain support for a reasonable treatment regimen Low back pain is the fifth most common reason for all physician visits in the United States ( 1 , 2 ) . Approximately one quarter of U.S. adults reported having low back pain lasting at least 1 whole day in the past 3 months ( 2 ) , and 7.6 % reported at least 1 episode of severe acute low back pain ( see Glossary ) within a 1-year period ( 3 ) . Low back pain is also very costly : Total incremental direct health care costs attributable to low back pain in the U.S. were estimated at $ 26.3 billion in 1998 ( 4 ) . In addition , indirect costs related to days lost from work are substantial , with approximately 2 % of the U.S. work force compensated for back injuries each year ( 5 ) . Many patients have self-limited episodes of acute low back pain and do not seek medical care ( 3 ) . Among those who do seek medical care , pain , disability , and return to work typically improve rapidly in the first month ( 6 ) . However , up to one third of patients report persistent back pain of at least moderate intensity 1 year after an acute episode , and 1 in 5 report substantial limitations in activity ( 7 ) . Approximately 5 % of the people with back pain disability account for 75 % of the costs associated with low back pain ( 8) . Many options are available for evaluation and management of low back pain . However , there has been little consensus , either within or between specialties , on appropriate clinical evaluation ( 9 ) and management ( 10 ) of low back pain . Numerous studies show unexplained , large variations in use of diagnostic tests and treatments ( 11 , 12 ) . Despite wide variations in practice , patients seem to experience broadly similar outcomes , although costs of care can differ substantially among and within specialties ( 13 , 14 ) . The purpose of this guideline is to present the available evidence for evaluation and management of acute and chronic low back pain ( see Glossary ) in primary care setting s. The target audience for this guideline is all clinicians caring for patients with low ( lumbar ) back pain of any duration , either with or without leg pain . The target patient population is adults with acute and chronic low back pain not associated with major trauma . Children or adolescents with low back pain ; pregnant women ; and patients with low back pain from sources outside the back ( nonspinal low back pain ) , fibromyalgia or other myofascial pain syndromes , and thoracic or cervical back pain are not included . These recommendations are based on a systematic evidence review summarized in 2 background papers by Chou and colleagues in this issue ( 15 , 16 ) from an evidence report by the American Pain Society ( 17 ) . The evidence report ( 17 ) discusses the evidence for the evaluation , and the 2 background papers ( 15 , 16 ) summarize the evidence for management . Methods The literature search for this guideline included studies from MEDLINE ( 1966 through November 2006 ) , the Cochrane Data base of Systematic Review s , the Cochrane Central Register of Controlled Trials , and EMBASE . The literature search included all English- language articles reporting on r and omized , controlled trials of nonpregnant adults ( age > 18 years ) with low back pain ( alone or with leg pain ) of any duration that evaluated a target medication and reported at least 1 of the following outcomes : back-specific function , generic health status , pain , work disability , or patient satisfaction .  The American College of Physicians ( ACP ) and the American Pain Society ( APS ) convened a multidisciplinary panel of experts to develop the key questions and scope used to guide the evidence report , review its results , and formulate recommendations . The background papers by Chou and colleagues ( 15 , 16 ) provide details about the methods used for the systematic evidence review . This guideline grade s its recommendations by using the ACP 's clinical practice guidelines grading system , adapted from the classification developed by the Grading of Recommendations , Assessment , Development , and Evaluation ( GRADE ) work group ( Appendix Table 1 ) ( 18 ) . The evidence in this guideline was first evaluated by the ACP/APS panel by using a system adopted from the U.S. Preventive Services Task Force for grading strength of evidence , estimating magnitude of benefits , and assigning summary ratings ( Appendix Tables 2 , 3 , and 4 ) ( 19 ) . The evidence was independently review ed by the ACP 's Clinical Efficacy Assessment Subcommittee . The ratings for individual low back pain interventions discussed in this guideline are summarized in Appendix Table 5 for acute low back pain ( < 4 weeks ' duration ) and in Appendix Table 6 for chronic/subacute low back pain ( > 4 weeks ' duration ) . This guideline considered interventions to have proven benefits only when they were supported by at least fair- quality evidence and were associated with at least moderate benefits ( or small benefits but no significant harms , costs , or burdens ) . Figures 1 and 2 present an accompanying algorithm . Appendix Table 1 . The American College of Physicians Clinical Practice Guidelines Grading System Appendix Table 2 . Methods for Grading the Strength of the Overall Evidence for an Intervention Appendix Table 3 . Definitions for Estimating Magnitude of Effects Appendix Table 4 . Recommendations and Summary Ratings Appendix Table 5 . Level of Evidence and Summary Grade s for Noninvasive Interventions in Patients with Acute Low Back Pain Appendix Table 6 . Level of Evidence and Summary Grade s for Noninvasive Interventions in Patients with Chronic or Subacute Low Back Pain Figure 1 . Initial evaluation of low back pain ( LBP Figure 2 . Management of low back pain ( LBP Recommendations : Evaluation of Low Back Pain Recommendation 1 : Clinicians should conduct a focused history and physical examination to help place patients with low back pain into 1 of 3 broad categories : nonspecific low back pain , back pain potentially associated with radiculopathy or spinal stenosis , or back pain potentially associated with another specific spinal cause . The history should include assessment of psychosocial risk factors , which predict risk for chronic disabling back pain ( strong recommendation , moderate- quality evidence ) . More than 85 % of patients who present to primary care have low back pain that can not reliably be attributed to a specific disease or spinal abnormality ( nonspecific low back pain [ see Glossary ] ) ( 20 ) . Attempts to identify specific anatomical sources of low back pain in such patients have not been vali date d in rigorous studies , and classification schemes frequently conflict with one another ( 21 ) . Moreover , no evidence suggests that labeling most patients with low back pain by using specific anatomical diagnoses improves outcomes . In a minority of patients presenting for initial evaluation in a primary care setting , low back pain is caused by a specific disorder , such as cancer ( approximately 0.7 % of cases ) , compression fracture ( 4 % ) , or spinal infection ( 0.01 % ) ( 22 ) . Estimates for prevalence of ankylosing spondylitis in primary care patients range from 0.3 % ( 22 ) to 5 % ( 23 ) . Spinal stenosis ( see Glossary ) and symptomatic herniated disc ( see Glossary ) are present in about 3 % and 4 % of patients , respectively . The cauda equina syndrome ( see Glossary ) is most commonly associated with massive midline disc herniation but is rare , with an estimated prevalence of 0.04 % among patients with low back pain ( 24 ) . A practical approach to assessment is to do a focused history and physical examination to determine the likelihood of specific underlying conditions and measure the presence and level of neurologic involvement ( 24 , 25 ) . Such an approach facilitates classification of patients into 1 of 3 broad categories : nonspecific low back pain , back pain potentially associated with radiculopathy ( see Glossary ) or spinal stenosis ( suggested by the presence of sciatica [ see Glossary ] or pseudoclaudication ) , and back pain potentially associated with another specific spinal cause . The latter category includes the small proportion of patients with serious or progressive neurologic deficits or underlying conditions requiring prompt evaluation ( such as tumor , infection , or the cauda equina syndrome ) , as well as patients with other conditions that may respond to specific treatments ( such as ankylosing spondylitis or vertebral compression fracture ) . Diagnostic triage into 1 of these 3 categories helps guide subsequent decision making . Clinicians should inquire about the location of pain , frequency of symptoms , and duration of pain , as well as any history of previous symptoms , treatment , and response to treatment . The possibility of low back pain due to problems outside the back , such as pancreatitis , nephrolithiasis , or aortic aneurysm , or systemic illnesses , such as endocarditis or viral syndromes , should be considered . All patients should be evaluated for the presence of rapidly progressive or severe neurologic deficits , including motor deficits at more than 1 level , fecal incontinence , and bladder dysfunction . The most frequent finding in the cauda equina syndrome is urinary retention ( 90 % sensitivity ) ( 24 ) . In patients without urinary retention , the probability of the cauda equina syndrome is approximately 1 in 10000 . Clinicians should also ask about risk factors for cancer and infection . In a large , prospect i ve study from a primary care setting , a history of cancer ( positive likelihood ratio , 14.7 ) , unexplained weight loss ( positive likelihood ratio , 2.7 ) , failure to improve after 1 month ( positive likelihood ratio , 3.0 ) , and age older than 50 years ( positive likelihood ratio , 2.7 ) were each associated with a higher likelihood for cancer ( 26 ) . The posttest probability of cancer in patients presenting with back pain increases from approximately 0.7 % to 9 % in patients with a history of cancer ( not including nonmelanoma skin cancer ) . In patients with any 1 of the other 3 risk factors , the likelihood of cancer only increases to approximately 1.2 % ( 26 ) . Features predicting the presence of vertebral infection have not been well studied Objectives Workplace exercise interventions are known to reduce musculoskeletal complaints and are widely offered to promote employee`s health . The psychosocial effects of such interventions are not clear . This review evaluates the effects of workplace exercise interventions on the psychosocial work environment and mental health . Methods A systematic review was performed by screening four scientific data bases ( Pubmed , Cochrane Data base , PsycINFO and Web of Science ) for published r and omized controlled trials in English from 1998 - 2018 . The review followed the PRISMA statement guidelines using the Cochrane tool for assessing risk of bias and the GRADE approach for assessment of quality . Two research ers independently performed data base search , study screening , and evaluation . Results Twenty two r and omized controlled trials met the inclusion criteria . Substantial heterogenicity in the studies included was found in study population s , types of intervention , and outcome measures performed . Quality assessment revealed a generally low level of quality in the studies included . This was partly the result of the limited possibilities for blinding and the self-reported outcome measures . Conclusion Workplace exercise interventions seem to have limited effects on mental health and the psychosocial work environment . Future studies should incorporate blinding and independent outcome measures Objective To examine the prevalence of outcome reporting bias — the selection for publication of a subset of the original recorded outcome variables on the basis of the results — and its impact on Cochrane review s. Design A nine point classification system for missing outcome data in r and omised trials was developed and applied to the trials assessed in a large , unselected cohort of Cochrane systematic review s. Research ers who conducted the trials were contacted and the reason sought for the non-reporting of data . A sensitivity analysis was undertaken to assess the impact of outcome reporting bias on review s that included a single meta- analysis of the review primary outcome . Results More than half ( 157/283 ( 55 % ) ) the review s did not include full data for the review primary outcome of interest from all eligible trials . The median amount of review outcome data missing for any reason was 10 % , whereas 50 % or more of the potential data were missing in 70 ( 25 % ) review s. It was clear from the publications for 155 ( 6 % ) of the 2486 assessable trials that the research ers had measured and analysed the review primary outcome but did not report or only partially reported the results . For reports that did not mention the review primary outcome , our classification regarding the presence of outcome reporting bias was shown to have a sensitivity of 88 % ( 95 % CI 65 % to 100 % ) and specificity of 80 % ( 95 % CI 69 % to 90 % ) on the basis of responses from 62 trialists . A third of Cochrane review s ( 96/283 ( 34 % ) ) contained at least one trial with high suspicion of outcome reporting bias for the review primary outcome . In a sensitivity analysis undertaken for 81 review s with a single meta- analysis of the primary outcome of interest , the treatment effect estimate was reduced by 20 % or more in 19 ( 23 % ) . Of the 42 meta-analyses with a statistically significant result only , eight ( 19 % ) became non-significant after adjustment for outcome reporting bias and 11 ( 26 % ) would have overestimated the treatment effect by 20 % or more . Conclusions Outcome reporting bias is an under-recognised problem that affects the conclusions in a substantial proportion of Cochrane review s. Individuals conducting systematic review s need to address explicitly the issue of missing outcome data for their review to be considered a reliable source of evidence . Extra care is required during data extraction , review ers should identify when a trial reports that an outcome was measured but no results were reported or events observed , and contact with trialists should be encouraged Background Gastrointestinal ( GI ) cancer is frequently diagnosed in people of working age , and many GI cancer patients experience work-related problems . Although these patients often experience difficulties returning to work , supportive work-related interventions are lacking . We have therefore developed a tailored work-related support intervention for GI cancer patients , and we aim to evaluate its cost-effectiveness compared with the usual care provided . If this intervention proves effective , it can be implemented in practice to support GI cancer patients after diagnosis and to help them return to work . Methods / Design We design ed a multicentre r and omized controlled trial with a follow-up of twelve months . The study population ( N = 310 ) will include individuals aged 18–63 years diagnosed with a primary GI cancer and employed at the time of diagnosis . The participants will be r and omized to the intervention or to usual care . ‘ Usual care ’ is defined as psychosocial care in which work-related issues are not discussed . The intervention group will receive tailored work-related support consisting of three face-to-face meetings of approximately 30 min each . Based on the severity of their work-related problems , the intervention group will be divided into groups receiving three types of support ( A , B or C ) . A different supportive healthcare professional will be available for each group : an oncological nurse ( A ) , an oncological occupational physician ( B ) and a multidisciplinary team ( C ) that includes an oncological nurse , oncological occupational physician and treating oncologist/physician . The primary outcome measure is return to work ( RTW ) , defined as the time to a partial or full RTW . The secondary outcomes are work ability , work limitations , quality of life , and direct and indirect costs . Discussion The hypothesis is that tailored work-related support for GI cancer patients is more effective than usual care in terms of the RTW . The intervention is innovative in that it combines oncological and occupational care in a clinical setting , early in the cancer treatment process . Trial registration METC protocol number NL51444.018.14/Netherl and s Trial Register number NTR5022 . Registered 6 March 2015 Interest in fatigue research has grown since the finding that fatigue/tiredness is the most frequently reported symptom of cancer and its treatment . But even though several authors have tried to conceptualise fatigue , its mechanisms are still poorly understood . The aim of this study was twofold : ( a ) to explore fatigue in cancer patients inductively , and ( b ) to compare experiences of fatigue/tiredness of healthy individuals with those of cancer patients to identify cancer-specific fatigue/tiredness and related concepts . A qualitative research strategy was adopted using a grounded-theory approach . The prospect i ve study took place in the oncology department of the Kantonsspital , St. Gallen , Switzerl and , with sample s of 20 cancer patients and 20 healthy individuals .  Unstructured , tape-recorded interviews were conducted to collect data . The transcripts of the interviews were analysed using content analysis and constant comparison . Different themes emerged between the two groups although both fitted a classification system that categorised fatigue into physical , affective and cognitive expressions of fatigue/tiredness . Physical signs were more frequent than affective and cognitive signs in both groups . In the cancer patients , fatigue involved decreased physical performance , extreme , unusual tiredness , weakness and an unusual need for rest , which was distinctly different for healthy persons . Affective and cognitive distress was also more prominent in cancer patients . Interestingly , the concept of malaise was not identified by either sample and not understood as an expression of fatigue by this German-speaking population . Linguistic differences in the description of fatigue/tiredness between healthy and ill individuals revealed different perceptions of the phenomenon . A step-like theory , explaining the production of fatigue/tiredness was tentatively put forward involving nociception , perception and expression of tiredness . The emerging concepts break tiredness/fatigue into an expression of physical , affective and cognitive tiredness/fatigue . The experience is different between healthy individuals and cancer patients . Care must be taken when drawing generalised conclusions but the results of the study identify and clarify ideas that might form an important basis for further , controlled studies OBJECTIVE Fatigue is commonly reported by patients with rheumatoid arthritis ( RA ) but is rarely a treatment target . The aim of this study was to explore the concept of fatigue as experienced by patients with RA . METHODS Fifteen patients with RA and fatigue ( > or = 7 on a 10-cm visual analog scale ) were individually interviewed and asked about the description , cause , consequence , and management of fatigue . Transcripts were systematic ally analyzed by 2 research ers independently , relevant phrases were coded , and earlier transcripts were checked for the emerging codes . A r and om sample of analyses were independently review ed . A total of 191 codes arising from the data were grouped into 46 categories and overarching themes . RESULTS Vivid descriptions reflect 2 types of fatigue : severe weariness and dramatic overwhelming fatigue . RA fatigue is different from normal tiredness because it is extreme , often not earned , and unresolving . Participants described physical , cognitive , and emotional components and attributed fatigue to inflammation , working the joints harder , and unrefreshing sleep . Participants described far-reaching effects on physical activities , emotions , relationships , and social and family roles . Participants used self-management strategies but with limited success . Most did not discuss fatigue with clinicians but when they did , they felt it was dismissed . Participants held negative views on the management of fatigue . CONCLUSION The data show that RA fatigue is important , intrusive , and overwhelming , and patients struggle to manage it alone . These data on the complexity of fatigue experiences will help clinicians design measures , interventions , and self-managment guidance UNLABELLED In July 2009 , the Medical Advisory Secretariat ( MAS ) began work on Non-Invasive Cardiac Imaging Technologies for the Diagnosis of Coronary Artery Disease ( CAD ) , an evidence -based review of the literature surrounding different cardiac imaging modalities to ensure that appropriate technologies are accessed by patients suspected of having CAD . This project came about when the Health Services Branch at the Ministry of Health and Long-Term Care asked MAS to provide an evidentiary platform on effectiveness and cost-effectiveness of non-invasive cardiac imaging modalities . After an initial review of the strategy and consultation with experts , MAS identified five key non-invasive cardiac imaging technologies for the diagnosis of CAD . Evidence -based analyses have been prepared for each of these five imaging modalities : cardiac magnetic resonance imaging , single photon emission computed tomography , 64-slice computed tomographic angiography , stress echocardiography , and stress echocardiography with contrast . For each technology , an economic analysis was also completed ( where appropriate ) . A summary decision analytic model was then developed to encapsulate the data from each of these reports ( available on the OHTAC and MAS website).The Non-Invasive Cardiac Imaging Technologies for the Diagnosis of Coronary Artery Disease series is made up of the following reports , which can be publicly accessed at the MAS website at : www.health.gov.on.ca/mas or at www.health.gov.on.ca/english/providers/program/mas/mas_about.htmlSINGLE PHOTON EMISSION COMPUTED TOMOGRAPHY FOR THE DIAGNOSIS OF CORONARY ARTERY DISEASE : An Evidence -Based Analysis STRESS ECHOCARDIOGRAPHY FOR THE DIAGNOSIS OF CORONARY ARTERY DISEASE : An Evidence -Based Analysis STRESS ECHOCARDIOGRAPHY WITH CONTRAST FOR THE DIAGNOSIS OF CORONARY ARTERY DISEASE : An Evidence -Based Analysis 64-Slice Computed Tomographic Angiography for the Diagnosis of Coronary Artery Disease : An Evidence -Based Analysis CARDIAC MAGNETIC RESONANCE IMAGING FOR THE DIAGNOSIS OF CORONARY ARTERY DISEASE : An Evidence -Based Analysis Pease note that two related evidence -based analyses of non-invasive cardiac imaging technologies for the assessment of myocardial viability are also available on the MAS website : POSITRON EMISSION TOMOGRAPHY FOR THE ASSESSMENT OF MYOCARDIAL VIABILITY : An Evidence -Based Analysis MAGNETIC RESONANCE IMAGING FOR THE ASSESSMENT OF MYOCARDIAL VIABILITY : an Evidence -Based Analysis The Toronto Health Economics and Technology Assessment Collaborative has also produced an associated economic report entitled : The Relative Cost-effectiveness of Five Non-invasive Cardiac Imaging Technologies for Diagnosing Coronary Artery Disease in Ontario [ Internet ] . Available from : http://theta.utoronto.ca/reports/?id=7 OBJECTIVE The objective of the analysis is to determine the diagnostic accuracy of single photon emission tomography ( SPECT ) in the diagnosis of coronary artery disease ( CAD ) compared to the reference st and ard of coronary angiography ( CA ) . The analysis is primarily meant to allow for indirect comparisons between non-invasive strategies for the diagnosis of CAD , using CA as a reference st and ard . SPECT : Cardiac SPECT , or myocardial perfusion scintigraphy ( MPS ) , is a widely used nuclear , non-invasive image acquisition technique for investigating ischemic heart disease . SPECT is currently appropriate for all aspects of detecting and managing ischemic heart disease including diagnosis , risk assessment /stratification , assessment of myocardial viability , and the evaluation of left ventricular function . Myocardial perfusion scintigraphy was originally developed as a two-dimensional planar imaging technique , but SPECT acquisition has since become the clinical st and ard in current practice . Cardiac SPECT for the diagnosis of CAD uses an intravenously administered radiopharmaceutical tracer to evaluate regional coronary blood flow usually at rest and after stress . The radioactive tracers thallium ( 201Tl ) or technetium-99 m ( 99mTc ) , or both , may be used to visualize the SPECT acquisition . Exercise or a pharmacologic agent is used to achieve stress . After the administration of the tracer , its distribution within the myocardium ( which is dependent on myocardial blood flow ) is imaged using a gamma camera . In SPECT imaging , the gamma camera rotates around the patients for 10 to 20 minutes so that multiple two-dimensional projections are acquired from various angles . The raw data are then processed using computational algorithms to obtain three-dimensional tomographic images . Since its inception , SPECT has evolved and its techniques/applications have become increasingly more complex and numerous . Accordingly , new techniques such as attenuation correction and ECG gating have been developed to correct for attenuation due to motion or soft-tissue artifact and to improve overall image clarity . RESEARCH QUESTIONS What is the diagnostic accuracy of SPECT for the diagnosis of CAD compared to the reference st and ard of CA?Is  SPECT cost-effective compared to other non-invasive cardiac imaging modalities for the diagnosis of CAD?What are the major safety concerns with SPECT when used for the diagnosis of CAD ? METHODS A preliminary literature search was performed across OVID MEDLINE , MEDLINE In-Process and Other Non-Indexed Citations , EMBASE , the Cochrane Library , and the International Agency for Health Technology Assessment ( INAHTA ) for all systematic review s/meta- analysis published between January 1 , 2004 and August 22 , 2009 . A comprehensive systematic review was identified from this search and used as a basis for an up date d search . A second comprehensive literature search was then performed on October 30 , 2009 across the same data bases for studies published between January 1 , 2002 and October 30 , 2009 . Abstract s were review ed by a single review er and , for those studies meeting the eligibility criteria , full-text articles were obtained . Reference lists were also h and - search ed for any additional studies . Inclusion Criteria Exclusion Criteria Systematic review s , meta-analyses , controlled clinical trials , and observational studies Minimum sample size of 20 patients who completed coronary angiographyUse of CA as a reference st and ard for the diagnosis of CAD Data available to calculate true positives ( TP ) , false positives ( FP ) , false negatives ( FN ) and true negatives (TN)Accuracy data reported by patient not by segmentEnglish language Non- systematic review s , case reportsGrey literature and abstract sTrials using planar imaging onlyTrials conducted in patients with non-ischemic heart disease Studies done exclusively in special population s ( e.g. , patients with left branch bundle block , diabetics , minority population s ) unless insufficient data available SUMMARY OF FINDINGS Eighty-four observational studies , one non-r and omized , single arm controlled clinical trial , and one poorly reported trial that appeared to be a r and omized controlled trial ( RCT ) met the inclusion criteria for this review . All studies assessed the diagnostic accuracy of myocardial perfusion SPECT  for the diagnosis of CAD using CA as a reference st and ard . Based on the results of these studies the following conclusions were made : According to very low quality evidence , the addition of attenuation correction to traditional or ECG-gated SPECT greatly improves the specificity of SPECT  for the diagnosis of CAD although this improvement is not statistically significant . A trend towards improvement of specificity was also observed with the addition of ECG gating to traditional SPECT.According to very low quality evidence , neither the choice of stress agent ( exercise or pharmacologic ) nor the choice of radioactive tracer ( technetium vs. thallium ) significantly affect the diagnostic accuracy of SPECT  for the diagnosis of CAD although a trend towards accuracy improvement was observed with the use of pharmacologic stress over exercise stress and technetium over thallium . Considerably heterogeneity was observed both within and between trials . This heterogeneity may explain why some of the differences observed between accuracy estimates for various subgroups were not statistically significant . More complex analytic techniques such as meta-regression may help to better underst and which study characteristics significantly influence the diagnostic accuracy of SPECT UNLABELLED In June 2008 , the Medical Advisory Secretariat began work on the Diabetes Strategy Evidence Project , an evidence -based review of the literature surrounding strategies for successful management and treatment of diabetes . This project came about when the Health System Strategy Division at the Ministry of Health and Long-Term Care subsequently asked the secretariat to provide an evidentiary platform for the Ministry 's newly released Diabetes Strategy .After an initial review of the strategy and consultation with experts , the secretariat identified five key areas in which evidence was needed . Evidence -based analyses have been prepared for each of these five areas : insulin pumps , behavioural interventions , bariatric surgery , home telemonitoring , and community based care . For each area , an economic analysis was completed where appropriate and is described in a separate report . To review these titles within the Diabetes Strategy Evidence series , please visit the Medical Advisory Secretariat Web site , http://www.health.gov.on.ca/english/providers/program/mas/mas_about.html,DIABETES STRATEGY EVIDENCE PLATFORM : Summary of Evidence -Based AnalysesContinuous Subcutaneous Insulin Infusion Pumps for Type 1 and Type 2 Adult Diabetics : An Evidence -Based Analysis Behavioural Interventions for Type 2 Diabetes : An Evidence -Based Analysis BARIATRIC SURGERY FOR PEOPLE WITH DIABETES AND MORBID OBESITY : An Evidence -Based Summary Community-Based Care for the Management of Type 2 Diabetes : An Evidence -Based Analysis Home Telemonitoring for Type 2 Diabetes  : An Evidence -Based Analysis Application of the Ontario Diabetes Economic Model ( ODEM ) to Determine the Cost-effectiveness and Budget Impact of Selected Type 2 Diabetes Interventions in Ontario OBJECTIVE The objective of this report is to determine the efficacy of specialized multidisciplinary community care for the management of type 2 diabetes compared to usual care . CLINICAL NEED TARGET POPULATION AND CONDITION Diabetes ( i.e. diabetes mellitus ) is a highly prevalent chronic metabolic disorder that interferes with the body 's ability to produce or effectively use insulin . The majority ( 90 % ) of diabetes patients have type 2 diabetes . ( 1 ) Based on the United Kingdom Prospect i ve Diabetes Study ( UKPDS ) , intensive blood glucose and blood pressure control significantly reduce the risk of microvascular and macrovascular complications in type 2 diabetics . While many studies have documented that patients often do not meet the glycemic control targets specified by national and international guidelines , factors associated with glycemic control are less well studied , one of which is the provider(s ) of care . Multidisciplinary approaches to care may be particularly important for diabetes management . According guidelines from the Canadian Diabetes Association ( CDA ) , the diabetes health care team should be multi- and interdisciplinary . Presently in Ontario , the core diabetes health care team consists of at least a family physician and /or diabetes specialist , and diabetes educators ( registered nurse and registered dietician ) . Increasing the role played by allied health care professionals in diabetes care and their collaboration with physicians may represent a more cost-effective option for diabetes management . Several systematic review s and meta-analyses have examined multidisciplinary care programs , but these have either been limited to a specific component of multidisciplinary care ( e.g. intensified education programs ) , or were conducted as part of a broader disease management program , of which not all were multidisciplinary in nature . Most review s also do not clearly define the intervention(s ) of interest , making the evaluation of such multidisciplinary community programs challenging . EVIDENCE -BASED ANALYSIS METHODS RESEARCH QUESTIONS What is the evidence of efficacy of specialized multidisciplinary community care provided by at least a registered nurse , registered dietician and physician ( primary care and /or specialist ) for the management of type 2 diabetes compared to usual care ? [ Henceforth referred to as Model 1]What is the evidence of efficacy of specialized multidisciplinary community care provided by at least a pharmacist and a primary care physician for the management of type 2 diabetes compared to usual care ? [ Henceforth referred to as Model 2 ] INCLUSION CRITERIA English language full-reportsPublished between January 1 , 2000 and September 28 , 2008R and omized controlled trials ( RCTs ) , systematic review s and meta-analysesType 2 diabetic adult population ( ≥18 years of age)Total sample size ≥30Describe specialized multidisciplinary community care defined as ambulatory-based care provided by at least two health care disciplines ( of which at least one must be a specialist in diabetes ) with integrated communication between the care providers . Compared to usual care ( defined as health care provision by non-specialist(s ) in diabetes , such as primary care providers ; may include referral to other health care professionals/services as necessary)≥6 months follow-up EXCLUSION CRITERIA Studies where discrete results on diabetes can not be abstract edPredominantly home-based interventions Inpatient-based interventions OUTCOMES OF INTEREST The primary outcomes for this review were glycosylated hemoglobin ( rHbA1c ) levels and systolic blood pressure ( SBP ) . SEARCH STRATEGY A literature search was performed on September 28 , 2008 using OVID MEDLINE , MEDLINE In-Process and Other Non-Indexed Citations , EMBASE , the Cumulative Index to Nursing & Allied Health Literature ( CINAHL ) , the Cochrane Library , and the International Agency for Health Technology Assessment ( INAHTA ) for studies published between January 1 , 2000 and September 28 , 2008 . Abstract s were review ed by a single review er and , for those studies meeting the eligibility criteria , full-text articles were obtained . Reference lists were also examined for any additional relevant studies not identified through the search . Articles with unknown eligibility were review ed with a second clinical epidemiologist , then a group of epidemiologists until consensus was established . The quality of evidence was assessed as high , moderate , low or very low according to GRADE methodology . Given the high clinical heterogeneity of the articles that met the inclusion criteria , specific models of specialized multidisciplinary community care were examined based on models of care that are currently being supported in Ontario , models of care that were commonly reported in the literature , as well as suggestions from an Expert Advisory Panel Meeting held on January 21 , 2009 . SUMMARY OF FINDINGS The initial search yielded 2,116 unique citations , from which 22 RCTs trials and nine systematic review s published were identified as meeting the eligibility criteria . Of these , five studies focused on care provided by at least a nurse , dietician , and physician ( primary care and /or specialist ) model of care ( Model 1 ; see Table ES 1 ) , while three studies focused on care provided by at least a pharmacist and primary care physician ( Model 2 ; see Table ES 2 ) . Based on moderate quality evidence , specialized multidisciplinary community care Model 2 has demonstrated a statistically and clinical ly significant reduction in HbA1c of 1.0 % compared with usual care . The effects of this model on SBP , however , are uncertain compared with usual care , based on very-low quality evidence . Specialized multidisciplinary community care Model 2 has demonstrated a statistically and clinical ly significant reduction in both HbA1c of 1.05 % ( based on high quality evidence ) and SBP of 7.13 mm Hg ( based on moderate quality evidence ) compared to usual care . For both models , the evidence does not suggest a preferred setting of care delivery ( i.e. , primary care vs. hospital outpatient clinic vs. community clinic ) . Table ES1 : Summary of Results of Meta-Analyses of the Effects of Multidisciplinary Care Model 1 Outcome Estimate of effect(95 % CI)Heterogeneity I(2)(p-value ) GRADE Glycosylated Hemoglobin ( HbA1c [%])-1.00 [ -1.27 , -0.73]4 % (p=0.37)Moderate- quality Subgroup : Moderate-to-High Quality -0.91 [ -1.19 , -0.62]0 % (p=0.74)Systolic Blood Pressure ( mm Hg)-2.04 [ -13.80 , 9.72]89 % (p=0.002)Very-low quality * Mean change from baseline to follow-up between intervention and control groupsTable ES2 : Summary of Results of Meta-Analyses of the Effects of Multidisciplinary Care Model 2 Outcome Estimate of effect(95 % CI)Heterogeneity I(2)(p-value ) GRADE Glycosylated Hemoglobin ( HbA1c [%])-1.05 [ -1.57 , -0.52]0 % (p=0.75)High- quality Systolic Blood Pressure ( mm Hg)-7.13 [ -11.78 , -2.48]46 % (p=0.17)Moderate quality * Mean change from baseline to follow-up between intervention and control groups Prognostic markers help to stratify patients for treatment by identifying patients with different risks of outcome ( e.g. recurrence of disease ) , and are important tools in the management of cancer and many other diseases . Systematic review and meta-analytical approaches to identifying the most valuable prognostic markers are needed because ( sometimes conflicting ) evidence relating to markers is often published across a number of studies . To investigate the practicality of this approach , an empirical investigation of a systematic review of  tumour markers for neuroblastoma was performed ; 260 studies of prognostic markers were identified , which considered 130 different markers . The reporting of these studies was often inadequate , in terms of both statistical analysis and presentation , and there was considerable heterogeneity for many important clinical /statistical factors . These problems restricted both the extraction of data and the meta- analysis of results from the primary studies , limiting feasibility of the evidence -based approach . Guidelines for reporting the results of primary prognostic marker studies in cancer , and other diseases , are given in order to facilitate both the interpretation of individual studies and the undertaking of systematic review s , meta- analysis and , ultimately , evidence -based practice . General availability of full individual patient data is a necessary step forward and would overcome the majority of problems encountered , including poorly reported summary statistics and variability in cutoff level , outcome assessed and adjustment factors used . It would also limit the problem of reporting bias , although publication bias will remain a concern until studies are prospect ively registered . Such changes in practice would help important evidence -based review s to be conducted in order to establish the most appropriate prognostic markers for clinical use , which should ultimately improve patient care Background Laboratory testing is an important clinical act with a valuable role in screening , diagnosis , management and monitoring of diseases or therapies . However , inappropriate laboratory test ordering is frequent , burdening health care spending and negatively influencing quality of care . Inappropriate tests may also result in false-positive results and potentially cause excessive downstream activities . Clinical decision support systems ( CDSSs ) have shown promising results to influence the test-ordering behaviour of physicians and to improve appropriateness . Order sets , a form of CDSS where a limited set of evidence -based tests are proposed for a series of indications , integrated in a computerised physician order entry ( CPOE ) have been shown to be effective in reducing the volume of ordered laboratory tests but convincing evidence that they influence appropriateness is lacking . The aim of this study is to evaluate the effect of order sets on the quality and quantity of laboratory test orders by physicians . We also aim to evaluate the effect of order sets on diagnostic error and explore the effect on downstream or cascade activities . Methods We will conduct a cluster r and omised controlled trial in Belgian primary care practice s. The study is powered to measure two outcomes . We will primarily measure the influence of our CDSS on the appropriateness of laboratory test ordering . Additionally , we will also measure the influence on diagnostic error . We will also explore the effects of our intervention on cascade activities due to altered results of inappropriate tests . Discussion We have design ed a study that should be able to demonstrate whether the CDSS aim ed at diagnostic testing is not only able to influence appropriateness but also safe with respect to diagnostic error . These findings will influence a lager , nationwide implementation of this CDSS.Trial registration Clinical Trials.gov , NCT02950142 Fatigue is one of the 10 most common reasons for visiting a physician . Yet little is known about its course or impact , from the patient 's perspective , on quality of life or utilization of medical care . The Dartmouth COOP Project , a primary care research network , conducted a one-year prospect i ve study comparing chief complaint fatigue ( CCF ) patients with two age/sex matched comparison groups ( N = 243 ) . Results show that almost 67 % of the CCF patients improved over one year ; however , they had much higher utilization rates and substantial limitations in physical and emotional function . Fatigue was associated with physical symptoms and interference with many aspects of daily life . We conclude that fatigue has a powerful , adverse effect on quality of life . We hope the findings may help physicians to better underst and and treat patients who seek care for fatigue Dr. Joseph Lau is a world-leading expert in meta- analysis and systematic review s. Currently a professor in the Department of Health Services , Policy and Practice and co-director of the Center for Evidence -based Medicine at Brown University , Professor Lau has applied evidence -based methods to a variety of clinical , biomedical and healthcare topics ; has developed reliable and efficient methods and tools to conduct systematic review s and meta-analyses ; and has advanced an underst and ing on the impact of factors that may contribute to differences of results in scientific studies . His past research includes cumulative meta- analysis of r and omized controlled trials , comparison of results from large trials and meta-analyses of small trials , effect of baseline risk in the interpretation of clinical trial results , and empirical evaluation of existing methods of combining data . His current focus is on a Web-based repository of systematic review data , review s of diagnostic tests , nutrition , clinical practice guidelines , and dissemination of evidence -based methods to varied health-care disciplines . This report is a conversation from an adapted version of an interview , more or less chronologically arranged , between Joseph C. Cappelleri as interviewer and Joseph Lau as interviewee , with Meghan Ingerick recording and transcribing the interview
Pooling was not appropriate for CFS.In studies with control groups of patients without the symptom of tiredness , prevalence of somatic disease was identical to those complaining of tiredness .
Depression , however , was more frequent among those with tiredness .
Conclusions Serious somatic disease is rare in patients complaining of tiredness .
Since prevalence is similar in patients without tiredness , the association may not be causal .
Background Tiredness is one of the most frequent complaints in primary care .
Although often self-limiting and frequently associated with psychosocial stress , patients but also their physicians are often uncertain regarding a serious cause and appropriate diagnostic work-up .
We conducted a systematic review and meta- analysis of studies reporting on differential diagnosis of fatigue in primary care .