Recently Published Projects

Objectives: This proposed evidence mapping project will summarize the data related to Flavan-3-ols and its connection to vascular health outcomes and risk factors.

Objectives: Structured Abstract Objectives. Many interventions are available to manage chronic pain; understanding the durability of treatment effects may assist with treatment selection. We sought to assess which noninvasive, nonpharmacological treatment for selected chronic pain conditions are associated with persistent improvement in function and pain outcomes at least 1 month after the completion of treatment. Data sources. Electronic databases (Ovid MEDLINE®, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews), through November 2017, reference lists, and ClinicalTrials.gov. Review methods. Using predefined criteria, we selected randomized controlled trials of noninvasive, nonpharmacological treatments for five common chronic pain conditions (chronic low back pain, chronic neck pain, osteoarthritis of the knee, hip, or hand, fibromyalgia, and tension headache) that addressed efficacy or harms compared with usual care, no treatment, waitlist, placebo, or sham intervention; compared with pharmacological therapy; or compared with exercise. Study quality was assessed, data extracted, and results summarized for function and pain. Only trials reporting results for at least 1 month post-intervention were included. We focused on the persistence of effects at short term (1 to < 6 months following treatment completion), intermediate term (≥6 to <12 months), and long term (≥12 months). Results. 218 publications (202 trials) were included. Many included trials were small. Evidence on outcomes beyond 1 year after treatment completion was sparse. Most trials enrolled patients with moderate baseline pain intensity (e.g., >5 on a 0 to 10 point numeric rating scale) and duration of symptoms ranging from 3 months to >15 years. The most common comparison was against usual care. Chronic low back pain: At short term, massage, yoga, and psychological therapies (primarily cognitive behavioral therapy [CBT]) (Strength of evidence [SOE]: Moderate) and exercise, acupuncture, spinal manipulation, and multidisciplinary rehabilitation (SOE: Low) were associated with slight improvements in function compared with usual care or inactive controls. Except for spinal manipulation, these interventions also improved pain. Effects on intermediate term function were sustained for yoga, spinal manipulation, multidisciplinary rehabilitation (SOE: Low), and psychological therapies (SOE: Moderate). Improvements in pain continued into intermediate term for exercise, massage and yoga (moderate effect, SOE: Low), mindfulness-based stress reduction (small effect, SOE: Low), spinal manipulation, psychological therapies, and multidisciplinary rehabilitation (small effects, SOE: Moderate). For acupuncture, there was no difference in pain at intermediate term, but a slight improvement at long term (SOE: Low). Psychological therapies were associated with slightly greater improvement than usual care or an attention control on both function and pain at short-term, intermediate-term, and long-term followup (SOE: Moderate). At short and intermediate term, multidisciplinary rehabilitation slightly improved pain compared with exercise (SOE: Moderate). High-intensity multidisciplinary rehabilitation (≥20 hours/week or >80 hours total) was not clearly better than nonhigh-intensity programs. Chronic neck pain: At short- and intermediate-terms, acupuncture and Alexander Technique were associated with slightly improved function compared with usual care (both interventions), sham acupuncture, or sham laser (SOE: Low), but no improvement in pain was seen at any time (SOE: Low). Short-term, low-level laser therapy was associated with moderate improvement in function and pain (SOE: Moderate). Combination exercise (any 3 of the following: muscle performance, mobility, muscle re-education, aerobic) demonstrated a slight improvement in pain and function short and long-term (SOE: Low). Osteoarthritis: For knee osteoarthritis, at short-term exercise and ultrasound demonstrated small short-term improvements in function compared with usual care, an attention control or sham procedure (SOE: Moderate for exercise, Low for ultrasound), which persisted into the intermediate term only for exercise (SOE: Low). Exercise was also associated with moderate improvement in pain (SOE: Low). Long term, the small improvement in function seen with exercise persisted, but there was no clear effect on pain (SOE: Low). Evidence was sparse on interventions for hip and hand osteoarthritis. Exercise for hip osteoarthritis was associated with slightly greater function and pain improvement than usual care short term (SOE: Low). The effect on function was sustained intermediate term (SOE: Low). Fibromyalgia: In the short term, acupuncture (SOE: Moderate), CBT, tai chi, qigong, and exercise (SOE: Low) were associated with slight improvements in function compared with an attention control, sham, no treatment or usual care. Exercise (SOE: Moderate) and CBT improved pain slightly and tai chi and qigong (SOE: Low) improved pain moderately in the short term. At intermediate term for exercise (SOE: Moderate), acupuncture and CBT (SOE: Low), slight functional improvements persisted and were also seen for myofascial release massage and multidisciplinary rehabilitation (SOE: Low); pain was improved slightly with multidisciplinary rehabilitation in the intermediate-term (SOE: Low). In the long term, small improvements in function continued for multidisciplinary rehabilitation but not for exercise or massage (SOE: Low for all); massage (SOE: Low) improved long-term pain slightly but no clear impact on pain for exercise (SOE: Moderate) or multidisciplinary rehabilitation (SOE: Low) was seen. Short-term CBT was associated with a slight improvement in function but not pain compared with pregabalin. Chronic tension headache: Evidence was sparse and the majority of trials were of poor quality. Spinal manipulation slightly improved function and moderately improved pain short-term versus usual care and laser acupuncture was associated with slight pain improvement short term compared with sham (SOE Low). There was no evidence suggesting increased risk for serious treatment-related harms for any of the interventions, although data on harms were limited. Conclusions. Exercise, multidisciplinary rehabilitation, acupuncture, cognitive behavioral therapy, and mind-body practices were most consistently associated with durable slight to moderate improvements in function and pain for specific chronic pain conditions. Our findings provided some support for clinical strategies that focused on use of nonpharmacological therapies for specific chronic pain conditions. Additional comparative research on sustainability of effects beyond the immediate post-treatment period is needed, particularly for conditions other than low back pain.

Objectives: Objectives. To systematically identify and summarize evaluations of measures of circulatory and respiratory compromise, focusing on measures that can be used in field assessment by emergency medical services to inform decisions about the level of trauma care needed. We identified research on the ability of different measures to predict whether a patient was seriously injured and thus required transport to the highest level of trauma care available. Data sources. We searched Ovid MEDLINE®, CINAHL®, and the Cochrane databases from 1996 through August 2017. Reference lists of included articles were reviewed for additional relevant citations. Review methods. We included studies of individual measures and measures that combined circulatory, respiratory, and level of consciousness assessment. Evaluations included diagnostic accuracy (sensitivity and specificity) and area under the receiver operating characteristic curve (AUROC). We used data provided to calculate values that were not reported and pooled estimates across studies when feasible. Results. We identified and included 138 articles reporting results of 134 studies. Circulatory compromise measures evaluated in these studies included systolic blood pressure, heart rate, shock index, lactate, base deficit, and heart rate variability or complexity. The respiratory measures evaluated included respiration rate, oxygen saturation, partial pressure of carbon dioxide, and need for airway support. Many different combination measures were identified, but most were evaluated in only one or two studies. Pooled AUROCs from out-of-hospital data were 0.67 for systolic blood pressure (moderate strength of evidence); 0.67 for heart rate, 0.72 for shock index, 0.77 for lactate, 0.70 for respiratory rate, and 0.89 for Revised Trauma Score combination measure (all low strength of evidence); and were considered poor to fair. The only AUROC that reached a level considered excellent was for the Glasgow Coma Scale, age, and arterial pressure (GAP) combination measure (AUROC, 0.96; estimate based on emergency department data). All of the measures had low sensitivities and comparatively high specificities (e.g., sensitivities ranging from 13% to 74% and specificities ranging from 62% to 96% for out-of-hospital pooled estimates). Conclusions. Physiologic measures usable in triaging trauma patients have been evaluated in multiple studies; however, their predictive utilities are moderate and far from ideal. Overall, the measures have low sensitivities, high specificities, and AUROCs in the poor-to-fair range. Combination measures that include assessments of consciousness seem to perform better, but whether they are feasible and valuable for out-of-hospital use needs to be determined. Modification of triage measures for children or older adults is needed, given that the measures perform worse in these age groups; however, research has not yet conclusively identified modifications that result in better performance.

Objectives: This systematic review is an update of a 2013 report that evaluated psychological and pharmacological treatments of adults with posttraumatic stress disorder (PTSD). The purpose of this review is to update the earlier work, expand the range of treatments examined, address earlier uncertainties, identify ways to improve care for PTSD patients, and reduce variation in existing treatment guidelines.

Objectives: Objective. Assess the effect of drug and nondrug interventions for treating acute symptoms associated with bipolar disorder (BD) and preventing relapse. Data sources. Ovid MEDLINE® and PsychInfo, the Cochrane Central Register of Controlled Trials, and Ovid Embase® bibliographic databases; hand searches of references of relevant systematic reviews through May, 2017. Review methods. Eligible studies included randomized controlled trials and prospective cohorts with comparator arms enrolling adults with BD of any type with 3 weeks followup for acute mania, 3 months for depression, and 6 months for maintenance treatments. We excluded acute mania and depression studies with greater than 50 percent attrition. Results. We synthesized evidence from 181 unique studies, 117 studies for 28 drugs, 64 studies for nondrug interventions. All drug findings with at least low-strength evidence were based on studies almost exclusively enrolling adults with BD-I. Asenapine, cariprazine, quetiapine, and olanzapine improved acute mania symptoms compared to placebo (low-strength evidence). However, improvements were of modest clinical significance, with values that were less than the minimally important difference, but still large enough that a reasonable proportion of participants likely received a benefit. Unpooled evidence indicated an overall beneficial effect of risperidone and ziprasidone on acute mania symptoms compared to placebo (low-strength evidence). Participants using antipsychotics, except quetiapine, reported more extrapyramidal symptoms compared to placebo, and those using olanzapine reported more clinically significant weight gain. Lithium improved acute mania in the short-term and prolonged time to relapse in the long-term compared to placebo (low-strength evidence). No difference was found between olanzapine and divalproex/valproate (low-strength evidence). For drugs not approved for BD, paliperidone also improved acute mania compared to placebo (low-strength evidence), while topiramate and allopurinol showed no benefit (low-strength evidence). Further, lithium improved acute mania better than topiramate, although withdrawals for adverse events were lower for topiramate. Only lithium reached a minimally important difference. All other drug comparisons to placebo or active controls for acute mania, depression, and maintenance had insufficient evidence. For psychosocial interventions, cognitive behavioral training (CBT) was no better for depression or mania symptoms than psychoeducation or other active psychosocial comparators (low-strength evidence). Systematic/collaborative care had no effect on relapse compared to inactive comparators (low-strength evidence). Evidence was insufficient for all other nondrug interventions. Conclusions. We found no high- or moderate-strength evidence for any intervention to effectively treat any phase of any type of BD compared with placebo or an active comparator. Low-strength evidence showed improved mania symptoms for all FDA-approved antipsychotics, except aripiprazole, when compared with placebo for adults with BD-I. Low-strength evidence also showed benefit from lithium for acute mania in the short-term and resulted in longer periods of maintenance versus placebo in adults with BD-I. Participants using atypical antipsychotics, except quetiapine, reported more extrapyramidal symptoms compared with placebo, and those using olanzapine reported more clinically significant weight gain. Evidence was insufficient for most nondrug interventions. Low-strength evidence showed no benefit for CBT on mood symptoms compared with active controls or systematic/collaborative care compared with inactive controls on relapse. Information on harms was limited across all drug and nondrug studies. Future studies of BD treatments will require innovative ways to increase study completion rates.