Archive
Screening for and Treatment of Suicide Risk Relevant to Primary Care: A Systematic Review for the U.S. Preventive Services Task Force
Source: Annals of Internet Medicine
Background:
In 2009, suicide accounted for 36 897 deaths in the United States.
Purpose:
To review the accuracy of screening instruments and the efficacy and safety of screening for and treatment of suicide risk in populations and settings relevant to primary care.
Data Sources:
Citations from MEDLINE, PsycINFO, the Cochrane Central Register of Controlled Trials, and CINAHL (2002 to 17 July 2012); gray literature; and a surveillance search of MEDLINE for additional screening trials (July to December 2012).
Study Selection:
Fair- or good-quality English-language studies that assessed the accuracy of screening instruments in primary care or similar populations and trials of suicide prevention interventions in primary or mental health care settings.
Data Extraction:
One investigator abstracted data; a second checked the abstraction. Two investigators rated study quality.
Data Synthesis:
Evidence was insufficient to determine the benefits of screening in primary care populations; very limited evidence identified no serious harms. Minimal evidence suggested that screening tools can identify some adults at increased risk for suicide in primary care, but accuracy was lower in studies of older adults. Minimal evidence limited to high-risk populations suggested poor performance of screening instruments in adolescents. Trial evidence showed that psychotherapy reduced suicide attempts in high-risk adults but not adolescents. Most trials were insufficiently powered to detect effects on deaths.
Limitation:
Treatment evidence was derived from high-risk rather than screen-detected populations. Evidence relevant to adolescents, older adults, and racial or ethnic minorities was limited.
Conclusion:
Primary care–feasible screening tools might help to identify some adults at increased risk for suicide but have limited ability to detect suicide risk in adolescents. Psychotherapy may reduce suicide attempts in some high-risk adults, but effective interventions for high-risk adolescents are not yet proven.
Primary Funding Source:
Agency for Healthcare Research and Quality
Screening for and Treatment of Suicide Risk Relevant to Primary Care: A Systematic Review for the U.S. Preventive Services Task Force
Source: Annals of Internal Medicine
Background:
In 2009, suicide accounted for 36 897 deaths in the United States.
Purpose:
To review the accuracy of screening instruments and the efficacy and safety of screening for and treatment of suicide risk in populations and settings relevant to primary care.
Data Sources:
Citations from MEDLINE, PsycINFO, the Cochrane Central Register of Controlled Trials, and CINAHL (2002 to 17 July 2012); gray literature; and a surveillance search of MEDLINE for additional screening trials (July to December 2012).
Study Selection:
Fair- or good-quality English-language studies that assessed the accuracy of screening instruments in primary care or similar populations and trials of suicide prevention interventions in primary or mental health care settings.
Data Extraction:
One investigator abstracted data; a second checked the abstraction. Two investigators rated study quality.
Data Synthesis:
Evidence was insufficient to determine the benefits of screening in primary care populations; very limited evidence identified no serious harms. Minimal evidence suggested that screening tools can identify some adults at increased risk for suicide in primary care, but accuracy was lower in studies of older adults. Minimal evidence limited to high-risk populations suggested poor performance of screening instruments in adolescents. Trial evidence showed that psychotherapy reduced suicide attempts in high-risk adults but not adolescents. Most trials were insufficiently powered to detect effects on deaths.
Limitation:
Treatment evidence was derived from high-risk rather than screen-detected populations. Evidence relevant to adolescents, older adults, and racial or ethnic minorities was limited.
Conclusion:
Primary care–feasible screening tools might help to identify some adults at increased risk for suicide but have limited ability to detect suicide risk in adolescents. Psychotherapy may reduce suicide attempts in some high-risk adults, but effective interventions for high-risk adolescents are not yet proven.
Primary Funding Source: Agency for Healthcare Research and Quality.
Firearm Legislation and Firearm-Related Fatalities in the United States
Firearm Legislation and Firearm-Related Fatalities in the United States
Source: JAMA Internal Medicine (Annals of Internal Medicine)
Importance
Over 30 000 people die annually in the United States from injuries caused by firearms. Although most firearm laws are enacted by states, whether the laws are associated with rates of firearm deaths is uncertain.
Objective
To evaluate whether more firearm laws in a state are associated with fewer firearm fatalities.
Design
Using an ecological and cross-sectional method, we retrospectively analyzed all firearm-related deaths reported to the Centers for Disease Control and Prevention Web-based Injury Statistics Query and Reporting System from 2007 through 2010. We used state-level firearm legislation across 5 categories of laws to create a “legislative strength score,” and measured the association of the score with state mortality rates using a clustered Poisson regression. States were divided into quartiles based on their score.
Setting
Fifty US states.
Participants
Populations of all US states.
Main Outcome Measures
The outcome measures were state-level firearm-related fatalities per 100 000 individuals per year overall, for suicide, and for homicide. In various models, we controlled for age, sex, race/ethnicity, poverty, unemployment, college education, population density, nonfirearm violence–related deaths, and household firearm ownership.
Results
Over the 4-year study period, there were 121 084 firearm fatalities. The average state-based firearm fatality rates varied from a high of 17.9 (Louisiana) to a low of 2.9 (Hawaii) per 100 000 individuals per year. Annual firearm legislative strength scores ranged from 0 (Utah) to 24 (Massachusetts) of 28 possible points. States in the highest quartile of legislative strength (scores of ≥9) had a lower overall firearm fatality rate than those in the lowest quartile (scores of ≤2) (absolute rate difference, 6.64 deaths/100 000/y; age-adjusted incident rate ratio [IRR], 0.58; 95% CI, 0.37-0.92). Compared with the quartile of states with the fewest laws, the quartile with the most laws had a lower firearm suicide rate (absolute rate difference, 6.25 deaths/100 000/y; IRR, 0.63; 95% CI, 0.48-0.83) and a lower firearm homicide rate (absolute rate difference, 0.40 deaths/100 000/y; IRR, 0.60; 95% CI, 0.38-0.95).
Conclusions and Relevance
A higher number of firearm laws in a state are associated with a lower rate of firearm fatalities in the state, overall and for suicides and homicides individually. As our study could not determine cause-and-effect relationships, further studies are necessary to define the nature of this association.
Are Organic Foods Safer or Healthier Than Conventional Alternatives?: A Systematic Review
Are Organic Foods Safer or Healthier Than Conventional Alternatives?: A Systematic Review
Source: Annals of Internal Medicine
Background: The health benefits of organic foods are unclear.
Purpose: To review evidence comparing the health effects of organic and conventional foods.
Data Sources: MEDLINE (January 1966 to May 2011), EMBASE, CAB Direct, Agricola, TOXNET, Cochrane Library (January 1966 to May 2009), and bibliographies of retrieved articles.
Study Selection: English-language reports of comparisons of organically and conventionally grown food or of populations consuming these foods.
Data Extraction: 2 independent investigators extracted data on methods, health outcomes, and nutrient and contaminant levels.
Data Synthesis: 17 studies in humans and 223 studies of nutrient and contaminant levels in foods met inclusion criteria. Only 3 of the human studies examined clinical outcomes, finding no significant differences between populations by food type for allergic outcomes (eczema, wheeze, atopic sensitization) or symptomatic Campylobacter infection. Two studies reported significantly lower urinary pesticide levels among children consuming organic versus conventional diets, but studies of biomarker and nutrient levels in serum, urine, breast milk, and semen in adults did not identify clinically meaningful differences. All estimates of differences in nutrient and contaminant levels in foods were highly heterogeneous except for the estimate for phosphorus; phosphorus levels were significantly higher than in conventional produce, although this difference is not clinically significant. The risk for contamination with detectable pesticide residues was lower among organic than conventional produce (risk difference, 30% [CI, −37% to −23%]), but differences in risk for exceeding maximum allowed limits were small. Escherichia coli contamination risk did not differ between organic and conventional produce. Bacterial contamination of retail chicken and pork was common but unrelated to farming method. However, the risk for isolating bacteria resistant to 3 or more antibiotics was higher in conventional than in organic chicken and pork (risk difference, 33% [CI, 21% to 45%]).
Limitation: Studies were heterogeneous and limited in number, and publication bias may be present.
Conclusion: The published literature lacks strong evidence that organic foods are significantly more nutritious than conventional foods. Consumption of organic foods may reduce exposure to pesticide residues and antibiotic-resistant bacteria.
Screening Women for Intimate Partner Violence: A Systematic Review to Update the 2004 U.S. Preventive Services Task Force Recommendation
Background:In 2004, the U.S. Preventive Services Task Force determined that evidence was insufficient to support screening women for intimate partner violence (IPV).
Purpose:To review new evidence on the effectiveness of screening and interventions for women in health care settings in reducing IPV and related health outcomes, the diagnostic accuracy of screening instruments, and adverse effects of screening and interventions.
Data Sources:MEDLINE and PsycINFO (January 2002 to January 2012), Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews (through fourth quarter 2011), Scopus, and reference lists.
Study Selection:English-language trials of the effectiveness of screening and interventions, diagnostic accuracy studies of screening instruments, and studies of any design about adverse effects.
Data Extraction:Investigators extracted data about study populations, designs, and outcomes, and rated study quality by using established criteria.
Data Synthesis:A large fair-quality trial of screening versus usual care indicated improved IPV and health outcomes for both groups, but no statistically significant differences between groups. Fifteen fair- and good-quality studies evaluated 13 screening instruments, and six instruments were highly accurate. Four fair- and goodquality trials of counseling reported reduced IPV and improved birth outcomes for pregnant women, reduced IPV for new mothers, and reduced pregnancy coercion and unsafe relationships for women in family-planning clinics. Fourteen studies indicated minimal adverse effects with screening, but some women experienced discomfort, loss of privacy, emotional distress, and concerns about further abuse.
Limitation:Trials were limited by heterogeneity, lack of true control groups, high loss to follow-up, self-reported measures, and lack of accepted reference standards.
Conclusion:Screening instruments accurately identify women experiencing IPV. Screening women for IPV can provide benefits that vary by population, while potential adverse effects have minimal impact on most women.
Primary Funding Source:Agency for Healthcare Research and Quality.
Prescription Medication Abuse and Illegitimate Internet-Based Pharmacies
Prescription Medication Abuse and Illegitimate Internet-Based Pharmacies
Source: Annals of Internal Medicine
Abuse of controlled prescription medications in the United States exceeds that of all illicit drugs combined except marijuana and has grown considerably in the past decade. Although available through traditional channels, controlled prescription medications can also be purchased on the Internet without a prescription. This issue has gained the attention of federal regulators, law enforcement, and the media, but physician awareness of the problem is scarce. This article describes the nature of the problem and its magnitude, discusses the challenges to federal and private efforts to combat illegitimate online pharmacies, and outlines strategies for physicians to recognize and minimize the unwarranted effects of the availability of these medications on the Internet.
Inviting Patients to Read Their Doctors’ Notes: Patients and Doctors Look Ahead Patient and Physician Surveys
Inviting Patients to Read Their Doctors’ Notes: Patients and Doctors Look Ahead Patient and Physician Surveys
Source: Annals of Internal Medicine
Background: Little is known about what primary care physicians (PCPs) and patients would expect if patients were invited to read their doctors’ office notes.
Objective: To explore attitudes toward potential benefits or harms if PCPs offered patients ready access to visit notes.
Design: The PCPs and patients completed surveys before joining a voluntary program that provided electronic links to doctors’ notes.
Setting: Primary care practices in 3 U.S. states.
Participants: Participating and nonparticipating PCPs and adult patients at primary care practices in Massachusetts, Pennsylvania, and Washington.
Measurements: Doctors’ and patients’ attitudes toward and expectations of open visit notes, their ideas about the potential benefits and risks, and demographic characteristics.
Results: 110 of 114 participating PCPs (96%), 63 of 140 nonparticipating PCPs (45%), and 37 856 of 90 203 patients (42%) completed surveys. Overall, 69% to 81% of participating PCPs across the 3 sites and 92% to 97% of patients thought open visit notes were a good idea, compared with 16% to 33% of nonparticipating PCPs. Similarly, participating PCPs and patients generally agreed with statements about potential benefits of open visit notes, whereas nonparticipating PCPs were less likely to agree. Among participating PCPs, 74% to 92% anticipated improved communication and patient education, in contrast to 45% to 67% of nonparticipating PCPs. More than one half of participating PCPs (50% to 58%) and most nonparticipating PCPs (88% to 92%) expected that open visit notes would result in greater worry among patients; far fewer patients concurred (12% to 16%). Thirty-six percent to 50% of participating PCPs and 83% to 84% of nonparticipating PCPs anticipated more patient questions between visits. Few PCPs (0% to 33%) anticipated increased risk for lawsuits. Patient enthusiasm extended across age, education, and health status, and 22% anticipated sharing visit notes with others, including other doctors.
Limitations: Access to electronic patient portals is not widespread, and participation was limited to patients using such portals. Response rates were higher among participating PCPs than nonparticipating PCPs; many participating PCPs had small patient panels.
Conclusion: Among PCPs, opinions about open visit notes varied widely in terms of predicting the effect on their practices and benefits for patients. In contrast, patients expressed considerable enthusiasm and few fears, anticipating both improved understanding and more involvement in care. Sharing visit notes has broad implications for quality of care, privacy, and shared accountability.
Primary Funding Source: The Robert Wood Johnson Foundation’s Pioneer Portfolio, Drane Family Fund, and Koplow Charitable Foundation.
A Comparison of the Effects of 2 Types of Massage and Usual Care on Chronic Low Back Pain
A Comparison of the Effects of 2 Types of Massage and Usual Care on Chronic Low Back Pain (PDF)
Source: Annals of International Medicine
Massage therapy may be effective for treatment of chronic back pain, with benefits lasting at least 6 months. No clinically meaningful difference between relaxation and structural massage was observed in terms of relieving disability or symptoms.
Stereotactic Body Radiation Therapy: Scope of the Literature
Stereotactic Body Radiation Therapy: Scope of the Literature
Source: Annals of Internal Medicine
Stereotactic body radiation therapy (SBRT) is derived from the techniques of stereotactic radiosurgery used to treat lesions in the brain and spine. It combines multiple finely collimated radiation beams and stereotaxy to deliver a high dose of radiation to an extracranial target in the body in a single dose or a few fractions.
This review provides a broad overview of the current state of SBRT for solid malignant tumors. Reviewers identified a total of 124 relevant studies. No published comparative studies address the relative effectiveness and safety of SBRT versus other forms of external-beam radiation therapy. Stereotactic body radiation therapy seems to be widely diffused as a treatment of various types of cancer, although most studies have focused only on its use for treating thoracic tumors.
Comparative studies are needed to provide evidence that the theoretical advantages of SBRT over other radiation therapies actually occur in the clinical setting. Only 1 small trial is currently under way.
