Maya Elin O'Neil

Screening for hepatocellular carcinoma in chronic liver disease: a systematic review.

Hepatocellular carcinoma (HCC) incidence and mortality have increased internationally over the past 4 decades (1, 2), with localized tumors accounting for most of the increase (3). The rationale for screening is that imaging tests, such as ultrasonography, may identify patients with early-stage HCC (4), and several potential options exist for treating patients with early-stage HCC, including liver transplantation, radiofrequency ablation, and liver resection (5). Several professional societies currently recommend HCC screening using imaging studies and tumor markers, primarily in patients at higher risk for HCC due to chronic hepatitis B or cirrhosis (57). However, recommendations for HCC screening remain controversial, in part because of concerns over the quality and paucity of existing evidence and because concerns about overdiagnosis and patient harms have been raised in other cancer screening programs (812). We conducted a systematic review of the published literature to better understand the incremental benefits and harms of routine HCC screening compared with clinical diagnosis. Methods This manuscript is part of a larger report commissioned by the Veterans Health Administration (13). A protocol describing the review plan was posted to a public Web site before the study was initiated (14). The analytic framework that guided this review was developed in collaboration with a panel of technical experts and is provided in Figure 1 of Supplement 1. Supplement 1. Figures Data Sources and Searches We searched MEDLINE, PsycINFO, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, and ClinicalTrials.gov from database inception to June 2013. We updated the MEDLINE, PsycINFO, and ClinicalTrials.gov searches in April 2014. The detailed search strategy is provided in Supplement 2. We obtained additional articles from systematic reviews, reference lists of pertinent studies, reviews, and editorials and by consulting technical advisors. Supplement 2. Search Strategy Study Selection Detailed inclusion and exclusion criteria are provided in Supplement 3. We included English-language, controlled clinical trials and observational studies that assessed the effects of screening on HCC-specific and all-cause mortality in adult populations. We used the term screening to include any surveillance or screening program in which specific tests (ultrasonography, computed tomography, magnetic resonance imaging, or -fetoprotein measurement) were performed explicitly to detect HCC in asymptomatic patients. Studies had to include a comparison group of patients who did not have routine screening. We excluded observational studies that did not consider important confounding factors, such as age, sex, and liver disease severity. Because we anticipated few clinical trials comparing screening versus no screening, we also included trials comparing frequencies of screening. We included studies of any population with chronic liver disease with or without cirrhosis but excluded studies of patients with prior HCC. We also searched for systematic reviews and primary studies that focused on potential harms of HCC screening. Supplement 3. Inclusion/Exclusion Criteria Seven investigators reviewed the titles and abstracts of citations identified from literature searches. If at least 1 reviewer indicated that a citation may be relevant, a second reviewer screened the citation for concordance. Two reviewers independently assessed the full-text articles for inclusion using the eligibility criteria in Supplement 3. Disagreements were resolved through consensus. Data Extraction and Quality Assessment From each study, we abstracted study design, objectives, setting, population characteristics (including sex, age, race or ethnicity, and liver disease cause and severity), patient eligibility and exclusion criteria, number of patients, years of enrollment, method and frequency of screening, adjusted and unadjusted mortality, and adverse events. A second author checked each entry for accuracy. Two reviewers independently assessed the quality of each trial by using a tool developed by the Cochrane Collaboration (15). We resolved disagreements through discussion. Each trial was given an overall summary assessment of low, high, or unclear risk of bias. Two reviewers graded the strength of evidence for outcomes by using published criteria that consider the consistency, coherence, directness, and applicability of a body of evidence as well as the internal validity of individual studies (16). We adapted existing tools to assess the quality of observational studies (1719). We do not report an overall summary assessment for observational studies because there are no validated criteria for doing so. Data Synthesis and Analysis We qualitatively synthesized the evidence on the benefits and harms of HCC screening. Clinical heterogeneity and the small number of trials precluded a meta-analysis of the findings. Role of the Funding Source The U.S. Department of Veterans Affairs Quality Enhancement Research Initiative supported this review but had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication. Results The electronic and manual searches yielded 13801 total citations, from which we identified 286 potentially relevant full-text articles. Twenty-two primary studies contained primary data relevant to the efficacy of HCC screening and met our inclusion criteria (Figure). Figure. Summary of evidence search and selection. RCT = randomized, controlled trial. Effects of Screening on Mortality Two trials and 18 observational studies provided very-low-strength evidence from which to draw conclusions about the mortality effects of HCC screening compared with no screening. The trials had substantial methodological flaws that threatened their internal validity, and their findings have limited applicability beyond the patient population with hepatitis B. The observational studies, most of which included patients with cirrhosis and hepatitis B, hepatitis C, or alcoholic liver disease, showed that screening detects patients with earlier-stage disease, who more frequently receive curative therapy. However, it is impossible to say whether the longer survival in patients with screen-detected disease was a true effect of screening or reflects lead- and length-time biases inherent to all observational studies, as well as selection biases that were common in many of the studies. Randomized, Controlled Trials Two community-based trials compared the effects on mortality of screening versus no screening (20, 21). Both were conducted in China in areas with high prevalence of HCC, and most participants had hepatitis B with or without cirrhosis (Table 1 of Supplement 4). One cluster randomized trial recruited screening group participants (n= 9757) from 1993 to 1995 and offered them serum -fetoprotein testing and ultrasonography every 6 months. Participants in the control group (n= 9443) were not made aware of the study nor actively followed. Death from HCC occurred less frequently in the screening group (83.2 vs. 131.5 per 100000 person-years; rate ratio, 0.63 [95% CI, 0.41 to 0.98]). Supplement 4. Tables However, the trial had several serious methodological limitations that gave it a high risk of bias (Table 2 of Supplement 4). One major concern is whether patients in both groups had the same risk for HCC. There is no information about randomization technique or allocation concealment and very little information about the baseline characteristics of the 2 groups, which is especially important in cluster randomized trials. Another concern is that weak methods used to ascertain the outcome measuredeath from HCCcould have introduced bias. If deaths were underreported in the control group, results could have been biased toward the null. On the other hand, if outcome adjudicators were not blinded, more deaths in the control group could have been misclassified as HCC-related, especially because the symptoms that define stage III HCC (cachexia, jaundice, and ascites) overlap substantially with symptoms of end-stage liver disease and no data were provided about liver disease severity in either group. Selective reporting and analysis of favorable outcomes were other concerns. Although the authors reported that vital status was available for all patients, overall mortality was not reported and there was no statistical adjustment for the effects of clustering. Finally, the study is less applicable to patients in the United States, in whom cirrhosis and thus HCC are usually secondary to hepatitis C, and the results probably have limited applicability to contemporary practice, in which the threshold for imaging for symptoms may be lower and the number of patients with incidentally discovered HCC on imaging is higher. The second trial used patient-level randomization stratified by township to assign patients with hepatitis B from 1989 to 1992 to the screening intervention (n= 3712), which consisted of serial -fetoprotein tests followed by ultrasonography for high -fetoprotein values, or the usual care group (n= 1869) (21). The population-based cancer registry used active case-finding techniques, and mortality was ascertained through the cancer registry and a population-based vital status registry. Cancer staging and cause of death were assessed by personnel blinded to intervention status. Only 28.8% of screening group participants completed all scheduled testing, but all participants completed at least 1 screening test. Fewer patients had stage III HCC in the screening group (19.8% vs. 41.0%; P value not reported). Hepatocellular carcinoma mortality was similar in both groups (1138 vs. 1114 per 100000 person-years; P= 0.86), as was all-cause mortality (1843 vs. 1788 per 100000 person-years; P value not s

Measuring Perceived Teacher Support and Its Influence on Adolescent Career Development

This article examines available measures of perceived teacher support and presents findings from two studies exploring the psychometric properties of the Teacher Support Scale (TSS). In Study 1, an exploratory factor analysis suggested a hierarchical structure with four first-order factors (Invested, Positive Regard, Expectations, and Accessible subscales) loading onto a single, higher order factor, excellent reliability, and concurrent validity. Perceived teacher support was significantly correlated with career decision-making self-efficacy and vocational outcome expectations. In Study 2, a confirmatory factor analysis did not provide replication of the initial model in a separate sample. However, the four, first-order factors explained a statistically significant amount of the variance in question items, and support was provided for their strong relationship to a single, higher order construct of teacher support. Recommendations for future practice and research on the role of teacher support in adolescent career development and suggestions for modifications to the measure are provided.

Intensive Care Unit Outcomes Among Patients With Lung Cancer in the Surveillance, Epidemiology, and End Results–Medicare Registry

PURPOSE Lung cancer is the leading cause of cancer-related mortality. Intensive care unit (ICU) use among patients with cancer is increasing, but data regarding ICU outcomes for patients with lung cancer are limited. PATIENTS AND METHODS We used the Surveillance, Epidemiology, and End Results (SEER) -Medicare registry (1992 to 2007) to conduct a retrospective cohort study of patients with lung cancer who were admitted to an ICU for reasons other than surgical resection of their tumor. We used logistic and Cox regression to evaluate associations of patient characteristics and hospital mortality and 6-month mortality, respectively. We calculated adjusted associations for mechanical ventilation receipt with hospital and 6-month mortality. RESULTS Of the 49,373 patients with lung cancer admitted to an ICU for reasons other than surgical resection, 76% of patients survived the hospitalization, and 35% of patients were alive 6 months after discharge. Receipt of mechanical ventilation was associated with increased hospital mortality (adjusted odds ratio, 6.95; 95% CI, 6.89 to 7.01; P < .001), and only 15% of these patients were alive 6 months after discharge. Of all ICU patients with lung cancer, the percentage of patients who survived 6 months from discharge was 36% for patients diagnosed in 1992 and 32% for patients diagnosed in 2005, whereas it was 16% and 11% for patients who received mechanical ventilation, respectively. CONCLUSION Most patients with lung cancer enrolled in Medicare who are admitted to an ICU die within 6 months of admission. To improve patient-centered care, these results should guide shared decision making between patients with lung cancer and their clinicians before an ICU admission.

The Effects of Pay-for-Performance Programs on Health, Health Care Use, and Processes of Care: A Systematic Review

Pay-for-performance (P4P) programs provide financial rewards or penalties to individual health care providers, groups of providers, or institutions according to their performance on measures of quality. In theory, if properly targeted and designed, P4P programs would help drive the behavior of providers and health care systems to improve the quality of care delivered, reduce unnecessary use of expensive health care services, and improve patient health outcomes (1). The idea is particularly relevant in the United States, where serious and broad gaps in health care quality have been tied in part to the long-standing fee-for-service system, which may provide incentives for service volume rather than quality (2). Despite their intuitive appeal, the promise of P4P programs in improving outcomes has not been empirically realized in past studies (36). The most recent systematic review examining the effectiveness of P4P programs in the United States found mixed evidence that P4P was associated with modest improvements in process-of-care outcomes but had little effect on patient outcomes (7). However, the literature has grown considerably since this review (which searched through 2012), and other countries, such as the United Kingdom, have gained considerable experience with large P4P initiatives that may provide information relevant to the United States. The purpose of the current review is to update and expand the prior systematic review in order to summarize current understanding of the effects of P4P programs targeted at physicians, groups, and institutions on process-of-care and patient outcomes in ambulatory and outpatient settings in and outside the United States. Methods This review was conducted according to a protocol that was developed using established reporting standards and posted to a public Web site (8) before the study was initiated (Appendix 1 of the Supplement). We used an analytic framework based on work by Damberg and colleagues (7) (Appendix 2 of the Supplement). Supplement. Supplemental Materials Data Sources and Searches We searched the following databases for studies that evaluated P4P programs: PubMed (1 June 2007 to 6 October 2016), MEDLINE, PsycINFO, CINAHL, Business Economics and Theory, Business Source Elite, Scopus, Faculty of 1000, and Gartner Research (1 June 2007 to 29 February 2016). We also performed targeted Google and PubMed searches aimed at well-known P4P demonstrations. We obtained additional articles from reference lists of pertinent studies, reviews, editorials, and expert recommendations. The search strategies are detailed in Appendix 3 of the Supplement. Study Selection Investigators reviewed titles and abstracts identified from literature searches. Two investigators independently assessed each potentially relevant article for inclusion using preestablished criteria (Appendices 4 and 5 of the Supplement). We included English-language studies of adult patients that evaluated ambulatory care or hospital-based P4P programs targeting health care providers at the individual, group, managerial, or institutional level and that reported any process-of-care, utilization, health, or intermediate health (clinical measures, such as a laboratory value or blood pressure) outcome. We included studies from other countries that have health systems similar to portions of the U.S. health care system. Studies examining only patient-targeted financial incentives, as well as payment models other than direct P4P, such as managed care, capitation, bundled payments, and accountable care organizations, were excluded. We also excluded studies that were not conducted in hospital or ambulatory settings, such as studies in long-term care facilities or nursing homes. We included clinical or cluster randomized, controlled trials (RCTs) of any size. We used a best-evidence approach, which is a method of specifying minimum inclusion criteria for nonrandomized studies (9). Inclusion of observational studies was limited to those with a comparison group, interrupted time series (ITS) studies, or large (n> 10000) cross-sectional or uncontrolled beforeafter studies. We excluded smaller uncontrolled studies because we had identified a large number of potentially relevant studies during a preliminary search and because the smaller uncontrolled studies were less likely to provide broadly applicable information given their limited scope and inherent methodological deficiencies. Data Extraction and Quality Assessment One investigator abstracted data elements from each included study, which were reviewed for accuracy by at least 1 additional investigator. We abstracted information on study design, sample size, country, program description, incentive structure (size and timing), target of the incentive, comparator, and outcomes (grouped as health, intermediate health, process-of-care, and utilization measures). Appendices 6 and 7 of the Supplement report these data. We classified studies according to 4 broad groupings: RCTs, ITS studies, controlled beforeafter studies, and uncontrolled beforeafter studies. Two investigators independently assessed study quality using the Newcastle-Ottawa Scale (10) for observational studies and the Cochrane Risk-of-Bias tool (11) for RCTs (Appendix 8 of the Supplement). Disagreements were resolved by consensus. Data Synthesis and Analysis We qualitatively synthesized the results of ambulatory and hospital studies separately and report process-of-care and patient outcomes for each setting. We synthesized results for specific P4P programs whenever possible. The review team evaluated the strength of the evidence according to guidance from the Agency for Healthcare Research and Quality (12). We did not perform meta-analysis because of the marked clinical heterogeneity across studies and the large number of observational studies. Role of the Funding Source The U.S. Department of Veterans Affairs Quality Enhancement Research Initiative supported this review but had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication. Results Search Results We reviewed 3418 titles and abstracts, identified 586 potentially eligible full-text articles, and ultimately included 69 studies (Figure). Fifty-eight studies were in ambulatory settings (Table 1 and Appendix 6 of the Supplement), 11 were in hospital settings (Table 2 and Appendix 7 of the Supplement), 52 reported process-of-care outcomes, and 38 assessed patient outcomes. The studies examined a wide range of P4P programs with varying incentive structures, goals, and contexts. The programs also differed in their purposes and targets, but the largest number of studies focused on managing chronic conditions in the primary care setting. Studies were conducted in a wide range of countries, including the United Kingdom (27 studies), the United States (17 studies), Taiwan (13 studies), France (3 studies), the Netherlands (3 studies), Canada (3 studies), Australia (1 study), South Korea (1 study), and Italy (1 study). There were 2 RCTs and 67 observational studies (10 ITS studies, 37 controlled beforeafter studies, and 20 large uncontrolled beforeafter studies). Figure. Literature flow diagram. P4P= pay-for-performance. * The current systematic review updates and expands on the review by Damberg and colleagues (7). Table 1. Findings From Studies of Ambulatory-Based Pay-for-Performance Programs Table 2. Findings From Studies of Hospital-Based Pay-for-Performance Programs A large number of studies evaluated different aspects of 2 large-scale national programs: the United Kingdoms Quality and Outcomes Framework (QOF) (24 studies) and Taiwans diabetes mellitus (DM-P4P) program (9 studies). The QOF is a nationwide program that began in 2004. It incentivizes primary care practices to achieve quality indicators that support clinical care and public health goals. Incentive payments can comprise up to approximately 30% of total income. Practices are aided by integrated health information technology that delivers automated prompts and decision support (36, 83). Taiwans DM-P4P program, implemented in 2001, allows physicians to voluntarily enroll in the program, and they in turn are given freedom to choose which patients to enroll (51). From 2001 to 2006, incentives targeted process-of-care outcomes, which were augmented with intermediate health outcome measures after 2006. Ambulatory CareBased Programs Process-of-Care Outcomes We found 9 studies from the United States evaluating the effects of P4P on process-of-care outcomes (14, 1620, 2224). Most of these studies examined outcomes over 4 years and had an average follow-up of 2.5 years; very few studies reported longer-term data. One RCT found that individual incentives increased appropriate response to high blood pressure but not use of guideline-recommended antihypertensive medication (14). Of the 6 studies that reported positive results (16, 18, 19, 2224), 1 did not have a control group (24), and selection bias was a serious concern in 3 others because of the way the control group was chosen (18, 22, 23). Two methodologically sound controlled beforeafter studies found no improvements in processes of care (17, 20). In general, there was evidence across 17 studies in the United Kingdom (2631, 33, 3638, 4147) that the QOF was associated with improvements in process-of-care measures, although the evidence was mixed among the more methodologically rigorous studies. There were 6 ITS studies. One showed substantial improvements in the prescription of long-acting reversible contraceptives (26), and another showed modest improvement in the initiation of diabetes medications (27). Another study found increased rates of depression screening and diagnoses, but antidepressant prescribing remained unchanged (31). In the other 3 studies, improvements had begun well bef

Factors associated with mild traumatic brain injury in veterans and military personnel: a systematic review.

A history of mild traumatic brain injury (mTBI) is common among military members who served in Operations Enduring Freedom, Iraqi Freedom, and New Dawn (OEF/OIF/OND). We completed a systematic review to describe the cognitive, mental health, physical health, functional, social, and cost consequences of mTBI in Veteran and military personnel. Of 2668 reviewed abstracts, the 31 included studies provided very low strength evidence for the questions of interest. Cognitive, physical, and mental health symptoms were commonly reported by Veterans/military members with a history of mTBI. On average, these symptoms were not significantly more common in those with a history of mTBI than in those without, although a lack of significant mean differences does not preclude the possibility that some individuals could experience substantial effects related to mTBI history. Evidence of potential risk or protective factors moderating mTBI outcomes was unclear. Although the overall strength of evidence is very low due to methodological limitations of included studies, our findings are consistent with civilian studies. Appropriate re-integration services are needed to address common comorbid conditions, such as treatment for post-traumatic stress disorder, substance use disorders, headaches, and other difficulties that Veterans and members of the military may experience after deployment regardless of mTBI history. (JINS, 2014, 20, 1-13).

The Effects of Cannabis Among Adults With Chronic Pain and an Overview of General Harms: A Systematic Review

The use of medicinal cannabis has become increasingly accepted in the United States and globally (1, 2). Eight states and the District of Columbia have legalized cannabis for recreational purposes, and 28 states and the District of Columbia have legalized it for medical purposes (3). Between 45% and 80% of persons who seek medical cannabis do so for pain management (4, 5). Among patients who are prescribed long-term opioid therapy for pain, up to 39% are also using cannabis (6, 7). Physicians will increasingly need to engage in evidence-based discussions with their patients about the potential benefits and harms of cannabis use. However, little comprehensive and critically appraised information exists about the benefits and harms of using cannabis to treat chronic pain. The objectives of this systematic review were to assess the efficacy of cannabis for treating chronic pain and to provide a broad overview of the short- and long-term physical and mental health effects of cannabis use in chronic pain and general patient populations. Methods Topic Development This article is part of a larger report commissioned by the Veterans Health Administration (8). A protocol describing the review plan was posted to a publicly accessible Web site before the study began (9). Data Sources and Searches We searched MEDLINE, Embase, PubMed, PsycINFO, Evidence-Based Medicine Reviews (including Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effectiveness, Health Technology Assessments, and Cochrane Central Register of Controlled Trials), and gray literature sources from database inception through February 2016. We updated this search specifically for new randomized controlled trials (RCTs) and systematic reviews in March 2017. We obtained additional articles from systematic reviews, reference lists, and expert recommendations. We also searched for ongoing, unpublished, or recently completed studies on ClinicalTrials.gov, the International Clinical Trials Registry Platform, the ISRCTN Registry, National Institutes of Health RePORTER, and the Agency for Healthcare Research and Quality Grants On-Line Database. Supplement 1 provides details on the search strategy, which we developed in consultation with a research librarian. Supplement. Online Supplement Study Selection We included English-language studies assessing the effect on nonpregnant adults of plant-based cannabis preparations or whole-plant extracts, such as nabiximols, a nonsynthetic pharmaceutical product with a standard composition and dose (oromucosal spray delivering tetrahydrocannabinol [THC], 2.7 mg, and cannabidiol, 2.5 mg). We did not include synthesized, pharmaceutically prepared cannabinoids, such as dronabinol or nabilone, because they are not available in dispensaries, and the efficacy of synthetic cannabinoid preparations for chronic pain was examined in 2 recent reviews (10, 11). We broadly defined plant-based cannabis preparations to include any preparation of the cannabis plant itself (for example, cannabis cigarettes and oils) or cannabis plant extracts to capture the variety of products available in U.S. dispensaries (12). To address the efficacy of cannabis for treating chronic pain, we included controlled clinical trials and cohort studies. This review focuses specifically on pain outcomes, although our larger report and search were designed to include other outcomes, such as sleep and quality of life (8). Because data about harms in the general population might be applicable to chronic pain populations, we examined harms broadly and reported whether the data were derived from studies of the general population or populations with chronic pain. To capture potential cannabis-related harms that may be of interest to clinicians and patients, but whose prevalence has not been well-characterized in larger-scale observational studies, we also included case series and descriptive studies of emerging harms. Supplement 2 provides the criteria we used for study selection. We searched for primary literature and systematic reviews; we dual-reviewed 5% of identified abstracts and all of the included full-text articles to ensure reliability. Disagreements were resolved by a third reviewer. Given the broad scope of this review, we summarized data from existing systematic reviews. We included only reviews that clearly reported their search strategy, reported inclusion and exclusion criteria, and appraised the internal validity of the included trials (13). We prioritized the most recent reviews and those with the broadest scope. In addition, we included individual studies that met inclusion criteria and either were published after the end search date of the included review or were not included in a prior systematic review. Data Extraction and Quality Assessment For all reports, 2 investigators abstracted details of study design, setting, patient population, intervention, and follow-up, as well as important co-interventions, health outcomes, health care use, and harms. Two reviewers independently assessed each trial (including those that were identified from a prior systematic review) as having low, high, or unclear risk of bias (ROB) for the pain outcome using a tool developed by the Cochrane Collaboration (14). Disagreements were resolved by consensus. To assess the ROB of observational studies for the pain outcome, we considered potential sources of bias most relevant to this evidence base and adapted existing assessment tools (15, 16) (Supplement 3). Data Synthesis and Analysis For the subgroup of neuropathic pain studies, we did a study-level meta-analysis of the proportion of patients experiencing clinically significant (30%) pain relief (Supplement 4), and we used the profile-likelihood random-effects model (17) to combine risk ratios. We assessed the magnitude of statistical heterogeneity among the studies using the standard Cochran chi-square test, the I 2 statistic (18). All analyses were done using Stata/IC, version 13.1 (StataCorp). Clinical heterogeneity, variation in outcomes reported, and the small number of trials precluded meta-analysis for other subgroups and outcomes, so we reported these qualitatively. After group discussion, we classified the overall strength of evidence for each outcome as high, moderate, low, or insufficient on the basis of the consistency, coherence, and applicability of the body of evidence as well as the internal validity of individual studies (19, 20). Role of the Funding Source The U.S. Department of Veterans Affairs Quality Enhancement Research Initiative supported the review but had no role in the design and conduct of the study; collection, management, analysis and interpretation of the data; preparation, review, and approval of the manuscript; or decision to submit the manuscript for publication. Results After reviewing 13674 titles and abstracts, we included 13 systematic reviews and 62 primary studies (Figure). Table 1 provides study-level details and the ROB rating for each of the chronic pain trials. Table 2 summarizes findings, including the ROB rating, by pain subgroup. Table 3 summarizes the harms in both pain and general populations. Supplement 5 provides additional study-level data from pain studies not included in prior reviews and from studies on general harms. Figure. Literature flow diagram. * Includes Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Health Technology Assessments, and Cochrane Central Register of Controlled Trials. Table 1. Characteristics and Findings of RCTs on Cannabis Extracts for Treating Chronic Pain* Table 2. Summary of Evidence of the Benefits of Cannabis in Populations With Chronic Pain Table 3. Summary of Evidence for the Harms of Cannabis in Chronic Pain and General Adult Populations Effects of Cannabis in Treating Chronic Pain We identified 22 RCTs (2142) from 2 recently published systematic reviews (10, 11) and an additional 8 studies (5 RCTs [4347] and 3 cohort studies [4850]) that met our inclusion criteria and were not included in prior reviews. The primary methods of continuous pain assessment were a visual analogue scale from 0 to 100 mm and a numerical rating scale (NRS) from 0 to 10 (where 0 indicated no pain and 10 indicated the worst possible pain). Some of the studies identified the proportion of participants who had clinically significant improvements in pain intensity (defined as 30% reduction, or approximately 2 points on the NRS and 20 mm on the visual analogue scale). Neuropathic Pain Thirteen trials examined the effects of cannabis-based preparations on neuropathic pain (Table 1). Participants had central or peripheral neuropathic pain related to various health conditions. Of these studies, 11 were rated as having low ROB (24, 27, 28, 30, 31, 33, 36, 39, 40, 43, 47), 1 as having unclear ROB (26), and 1 as having high ROB (35). Overall, we found low-strength evidence that cannabis may alleviate neuropathic pain in some patients (Table 2). Studies generally did not find clinically significant between-group differences on continuous pain scales, but a higher proportion of intervention patients had clinically significant pain relief up to several months later. Across 9 studies, intervention patients were more likely to report at least 30% improvement in pain (risk ratio, 1.43 [95% CI, 1.16 to 1.88]; I 2= 38.6%; P= 0.111) (Supplement 4). Most studies were small, few reported outcomes beyond 2 to 3 weeks, and none reported long-term outcomes. In the largest RCT, 246 patients with peripheral neuropathic pain self-titrated nabiximols up to a maximum dosage of 24 sprays per day or received a placebo (27). Those who completed the study (79 in the nabiximols group and 94 in the placebo group) and responded positively to the intervention had a significant decrease in pain (odds ratio, 1.97 [CI, 1.05 to 3.70]). However, among all participants, including those who did not have an intervention response, the reductio

Predictive effects of mother and peer influences on increases in adolescent eating disorder risk factors and symptoms: A 3-year longitudinal study

OBJECTIVE To investigate the relation of maternal and peer attitudes and behaviors to changes in eating disorder risk factors and symptoms in adolescent females. METHOD We tested whether maternal and peer eating attitudes, behaviors, and deficits in social support at baseline predicted subsequent increases in eating disorder risk factors and symptoms among 483 late adolescent females followed over 3 years. RESULTS Data provide partial support for hypotheses, as eating disorder risk factors and symptoms increased over time and maternal thin ideal internalization significantly predicted a future increases in adolescent bulimic symptoms. There were no significant predictors of adolescent thin ideal internalization or body dissatisfaction. DISCUSSION Findings only partially support the hypothesis that unhealthy attitudes and behaviors of mothers increase risk for eating disorder symptoms in their late adolescent daughters. These results underscore why eating disorder prevention programs should be based on risk factor research that has used prospective and rigorous designs.

Comparing the Neuropsychological Test Performance of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans with and without Blast Exposure, Mild Traumatic Brain Injury, and Posttraumatic Stress Symptoms

To compare neuropsychological test performance of Veterans with and without mild traumatic brain injury (MTBI), blast exposure, and posttraumatic stress disorder (PTSD) symptoms. We compared the neuropsychological test performance of 49 Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) Veterans diagnosed with MTBI resulting from combat blast-exposure to that of 20 blast-exposed OEF/OIF Veterans without history of MTBI, 23 OEF/OIF Veterans with no blast exposure or MTBI history, and 40 matched civilian controls. Comparison of neuropsychological test performance across all four participant groups showed a complex pattern of mixed significant and mostly nonsignificant results, with omnibus tests significant for measures of attention, spatial abilities, and executive function. The most consistent pattern was the absence of significant differences between blast-exposed Veterans with MTBI history and blast-exposed Veterans without MTBI history. When blast-exposed Veteran groups with and without MTBI history were aggregated and compared to non-blast-exposed Veterans, there were significant differences for some measures of learning and memory, spatial abilities, and executive function. However, covariation for severity of PTSD symptoms eliminated all significant omnibus neuropsychological differences between Veteran groups. Our results suggest that, although some mild neurocognitive effects were associated with blast exposure, these neurocognitive effects might be better explained by PTSD symptom severity rather than blast exposure or MTBI history alone.

Assessing Phonemic Awareness in Preschool and Kindergarten: Development and Initial Validation of First Sound Fluency

This article presents initial findings from a study examining First Sound Fluency (FSF), which is a brief measure of early phonemic awareness (PA) skills. Students in prekindergarten and kindergarten (preK and K) were assessed three times (fall, winter, and spring) over one school year, which resulted in multiple reliability and validity coefficients. In addition, a subset of students in both preK and K was assessed monthly between benchmark periods using alternate forms of the FSF measure to estimate delayed alternate-form reliability. The FSF measure displayed adequate reliability and validity for decision making in early literacy for students in both grades. Implications of these findings are discussed.

So many options, where do we start? An overview of the care transitions literature.

BACKGROUND Health systems are faced with a large array of transitional care interventions and patient populations to whom such activities might apply. PURPOSE To summarize the health and utilization effects of transitional care interventions, and to identify common themes about intervention types, patient populations, or settings that modify these effects. DATA SOURCES PubMed and Cochrane Database of Systematic Reviews (January 1950-May 2014), reference lists, and technical advisors. STUDY SELECTION Systematic reviews of transitional care interventions that reported hospital readmission as an outcome. DATA EXTRACTION We extracted transitional care procedures, patient populations, settings, readmissions, and health outcomes. We identified commonalities and compiled a narrative synthesis of emerging themes. DATA SYNTHESIS Among 10 reviews of mixed patient populations, there was consistent evidence that enhanced discharge planning and hospital-at-home interventions reduced readmissions. Among 7 reviews in specific patient populations, transitional care interventions reduced readmission in patients with congestive heart failure and general medical populations. In general, interventions that reduced readmission addressed multiple aspects of the care transition, extended beyond hospital stay, and had the flexibility to accommodate individual patient needs. There was insufficient evidence on how caregiver involvement, transition to sites other than home, staffing, patient selection practices, or care settings modified intervention effects. CONCLUSIONS Successful interventions are comprehensive, extend beyond hospital stay, and have the flexibility to respond to individual patient needs. The strength of evidence should be considered low because of heterogeneity in the interventions studied, patient populations, clinical settings, and implementation strategies.