Neil M. Paige

Diagnosing and Managing Common Food Allergies: A Systematic Review

CONTEXT There is heightened interest in food allergies but no clear consensus exists regarding the prevalence or most effective diagnostic and management approaches to food allergies. OBJECTIVE To perform a systematic review of the available evidence on the prevalence, diagnosis, management, and prevention of food allergies. DATA SOURCES Electronic searches of PubMed, Cochrane Database of Systematic Reviews, Cochrane Database of Abstracts of Reviews of Effects, and Cochrane Central Register of Controlled Trials. Searches were limited to English-language articles indexed between January 1988 and September 2009. STUDY SELECTION Diagnostic tests were included if they had a prospective, defined study population, used food challenge as a criterion standard, and reported sufficient data to calculate sensitivity and specificity. Systematic reviews and randomized controlled trials (RCTs) for management and prevention outcomes were also used. For foods where anaphylaxis is common, cohort studies with a sample size of more than 100 participants were included. DATA EXTRACTION Two investigators independently reviewed all titles and abstracts to identify potentially relevant articles and resolved discrepancies by repeated review and discussion. Quality of systematic reviews and meta-analyses was assessed using the AMSTAR criteria, the quality of diagnostic studies using the QUADAS criteria most relevant to food allergy, and the quality of RCTs using the Jadad criteria. DATA SYNTHESIS A total of 12,378 citations were identified and 72 citations were included. Food allergy affects more than 1% to 2% but less than 10% of the population. It is unclear if the prevalence of food allergies is increasing. Summary receiver operating characteristic curves comparing skin prick tests (area under the curve [AUC], 0.87; 95% confidence interval [CI], 0.81-0.93) and serum food-specific IgE (AUC, 0.84; 95% CI, 0.78-0.91) to food challenge showed no statistical superiority for either test. Elimination diets are the mainstay of therapy but have been rarely studied. Immunotherapy is promising but data are insufficient to recommend use. In high-risk infants, hydrolyzed formulas may prevent cows milk allergy but standardized definitions of high risk and hydrolyzed formula do not exist. CONCLUSION The evidence for the prevalence and management of food allergy is greatly limited by a lack of uniformity for criteria for making a diagnosis.

Electronic Patient Portals: Evidence on Health Outcomes, Satisfaction, Efficiency, and Attitudes: A Systematic Review

BACKGROUND Patient portals tied to provider electronic health record (EHR) systems are increasingly popular. PURPOSE To systematically review the literature reporting the effect of patient portals on clinical care. DATA SOURCES PubMed and Web of Science searches from 1 January 1990 to 24 January 2013. STUDY SELECTION Hypothesis-testing or quantitative studies of patient portals tethered to a provider EHR that addressed patient outcomes, satisfaction, adherence, efficiency, utilization, attitudes, and patient characteristics, as well as qualitative studies of barriers or facilitators, were included. DATA EXTRACTION Two reviewers independently extracted data and addressed discrepancies through consensus discussion. DATA SYNTHESIS From 6508 titles, 14 randomized, controlled trials; 21 observational, hypothesis-testing studies; 5 quantitative, descriptive studies; and 6 qualitative studies were included. Evidence is mixed about the effect of portals on patient outcomes and satisfaction, although they may be more effective when used with case management. The effect of portals on utilization and efficiency is unclear, although patient race and ethnicity, education level or literacy, and degree of comorbid conditions may influence use. LIMITATION Limited data for most outcomes and an absence of reporting on organizational and provider context and implementation processes. CONCLUSION Evidence that patient portals improve health outcomes, cost, or utilization is insufficient. Patient attitudes are generally positive, but more widespread use may require efforts to overcome racial, ethnic, and literacy barriers. Portals represent a new technology with benefits that are still unclear. Better understanding requires studies that include details about context, implementation factors, and cost.

Screening for Osteoporosis in Men: A Systematic Review for an American College of Physicians Guideline

Osteoporosis in men is substantially underdiagnosed and undertreated in the United States and worldwide (1). Looker and colleagues (2), evaluating the Third National Health and Nutrition Examination Survey database in 1997, estimated that between 300000 and 2 million Americans older than age 50 years have osteoporosis and up to 13 million may have low bone mass. A 60-year-old white man has a 25% lifetime risk for an osteoporotic fracture (3), and the consequences of the fracture can be severe. The 1-year mortality rate in men after hip fracture is twice that in women (1). Diagnostic evaluation and treatment of men at high risk for fracture remains low, despite the prevalence of this condition in men (1, 4). Dual-energy x-ray absorptiometry (DXA) is the current gold standard test for diagnosing osteoporosis in people without a known osteoporotic fracture. It is, however, an imperfect test, identifying less than one half of the people who progress to have an osteoporotic fracture. For example, in the Rotterdam Study (5), the sensitivity of DXA-determined osteoporosis was only 44% and 21% in identifying elderly women and men, respectively, who subsequently had a nonvertebral fracture. Clearly, factors other than low bone mass are important in identifying patients at elevated risk for osteoporotic fracture. An increased risk for falling may explain why some factors are identified as risk factors for osteoporotic fractures independent of bone mineral density (BMD) (for example, tricyclic antidepressants) (6). Although imperfect, a strong and graded relationship exists between DXA-determined BMD and future osteoporotic fracture in women and men (7, 8). The Rotterdam Study (7) reported that the incidence of vertebral and hip fracture approximately doubled for every SD decrease in BMD at the lumbar spine and femoral neck, respectively. Furthermore, pharmacologic treatment of men with low DXA-determined BMD has been shown to decrease the risk for subsequent fractures (9). Some organizations have called for universal screening of older men with DXA testing (5, 10). Although these universal DXA screening strategies would probably increase the diagnosis rate of undetected male osteoporosis, such strategies may not be cost-effective in all men. Schousboe and colleagues (11) recently reported that universal screening would probably be cost-effective only in men age 80 years or older, although this result was sensitive to the cost of treatment. In addition, DXA is not portable, requires a special technician, and is not readily available in many locales (5, 1013), and efforts to find a non-DXA test that is suitable for widespread use have not succeeded to date. We conducted a systematic review of the published literature to identify evidence relevant to screening men for osteoporosis. We focused solely on studies concerning the identification of men with risk factors for fracture that may be mediated through low BMD. Recent reviews have summarized the evidence on non-BMD risk factors, including determining who is at increased risk for falls (14) and treatment of persons at elevated risk (15). Our aims were to determine the risk factors for low BMDmediated osteoporotic fracture in men that could be used to help select patients for BMD testing and whether non-DXA screening tests could be reliably used to diagnose DXA-defined osteoporosis. Methods Search Strategy and Study Selection We searched MEDLINE from 1990 through July 2007 to find articles relevant to risk factors for low BMD and osteoporotic fracture and screening tests for male osteoporosis (Table 1). In addition to our MEDLINE search, we performed reference mining of retrieved articles and previous reviews and solicited articles from experts. Table 1. Search Strategy To be included in our review, a study had to measure risk factors for low BMD or osteoporotic fracture in men or compare a non-DXA index screening test with a gold standard reference test in men (DXA or, for calcaneal ultrasonography, fracture occurrence). Eligible risk factors were judged to be mediated through low BMD on the basis of published literature or expert opinion. Eligible study designs included controlled clinical trials, cohort studies and case series, casecontrol studies, and systematic reviews or meta-analyses. We excluded case reports, nonsystematic reviews, letters to the editor, and other similar publications. Four trained researchers (working in pairs) reviewed the list of titles and selected articles for further review. They reviewed each retrieved article with a brief screening form that collected data on demographic characteristics, study design, and clinical outcomes. Data Abstraction Two physicians independently abstracted data and resolved differences by repeated review. For studies evaluating the performance of osteoporosis screening tests, a statistician extracted sensitivity, specificity, and their SEs at the relevant quantitative ultrasonography or questionnaire threshold. We calculated the SEs of sensitivity and specificity for studies that did not report them (16). If the sensitivity or specificity was not reported in a study and if they could not be calculated from the given data, we excluded the study from quantitative analysis. We contacted the original authors of some studies to obtain the sample sizes per group needed to perform this calculation. Quality Assessment To evaluate the quality of the included diagnostic studies, we evaluated for potential sources of bias. Our quality appraisal included components from the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) evaluation tool (17) and additional quality variables noted as important in other published studies (11). The QUADAS tool is a 14-item questionnaire that evaluates the bias, data variability, and quality of reporting in diagnostic accuracy studies (18). Data Synthesis For studies of risk factors for low BMDmediated osteoporotic fracture, we identified a meta-analysis and summarized the results. We assessed the study by using the Overview Quality Assessment Questionnaire (19) and judged it to be of sufficiently high quality and acceptable to use the results. We summarized studies published after this meta-analysis and presented them narratively. For studies of non-DXA screening tests that met inclusion criteria and were clinically appropriate, we reviewed test thresholds for determining osteoporosis across studies to see whether they were comparable and evaluate whether statistical pooling was appropriate. This analysis revealed these studies to be too heterogeneous for statistical pooling. Therefore, where data were available, we abstracted information on the sensitivity and specificity of the screening tests and graphed the data points of studies evaluating the same screening method on receiver-operating characteristic (ROC) curves (20). Rating the Body of Evidence We assessed the overall quality of evidence for outcomes by using a method developed by the Grading of Recommendations, Assessment, Development, and Evaluation group (GRADE) (21), which classifies the grade of evidence across outcomes (Table 2). Table 2. GRADE Categories of Quality of Evidence Role of the Funding Source The U.S. Department of Veterans Affairs Health Services Research and Development Evidence Synthesis Activity Pilot Program provided funding. The funding source was involved in development of the key questions and provided review on a draft version of the evidence report, but it had no role in the decision to submit the manuscript for publication. Results Literature Flow Our initial literature search identified 614 titles (Figure 1): 540 from the electronic search, 69 from reference mining, and 5 from content experts. Of these, 177 assessed risk factors for low BMDmediated osteoporotic fracture and 20 evaluated screening tools for osteoporosis. The studies that addressed screening tools for osteoporosis enrolled a total of 28359 participants (2248). Table 3 shows details of these screening studies. Figure 1. Study flow diagram. Some articles assessed multiple risk factors. A total of 614 titles were identified for review; 20 articles evaluated male osteoporosis screening tools and were included in the analysis. BMD = bone mineral density; PSA = prostate-specific antigen. Table 3. Characteristics of NonDual-Energy X-Ray Absorptiometry Osteoporosis Screening Tests Risk Factors for Low BMDMediated Fracture We identified a systematic review and meta-analysis by Espallargues and colleagues (49) of risk factors for low BMDmediated osteoporotic fracture to guide bone densitometry assessments. Espallargues and colleagues searched several databases up to 1997 and identified 94 cohort studies, 72 casecontrol studies, and 1 randomized clinical trial. Most studies were performed in participants older than age 50 years and used American or European study populations. Where feasible, the authors used fixed-effects methods to provide meta-analytic pooled estimates of risk. They classified risk factors into the following groups: high risk, an associated relative risk or odds ratio of 2 or greater; moderate risk, risk values of between 1.0 and 2.0; no risk, risk values close or equal to the null value, or even a protective effect; and unclassifiable, data were insufficient to reach a conclusion or contradictory. Strengths of this review include the search strategy and identification of a very large number of articles, categorization of risk factors, and use of meta-analytic techniques to provide summary results. The main limitation is that data specific for men are not presented. The authors performed separate analyses for men and women, found no important differences, and presented results for both sexes combined. The most important high-risk factors relevant to men are age older than 70 years and low body weight (body mass index <20 to 25 m/kg2). Additional important high-risk factors are physical inactivity, corticosteroid use, and prev

IMPROVEMENT IN EMOTIONAL WELL-BEING AND RELATIONSHIPS OF USERS OF SILDENAFIL

PURPOSE We estimated the association of sildenafil use with erectile function, relationship with sexual partner, functional status and emotional well-being in men with erectile dysfunction. MATERIALS AND METHODS Letters were mailed to eligible patients at a university hospital urology and internal medicine clinic, and university affiliated community primary care clinics by the primary care provider or urologist inviting them to participate in the study. Of the eligible sample 124 men (53%) completed and returned a survey, including 85 who reported current sildenafil use. Change scores in these patients were calculated using the International Index of Erectile Function, marital interaction scale from the Cancer Rehabilitation Evaluation System Short Form, 5-item emotional well-being scale of the RAND 36-Item Health Survey and 12-Item Short Form Health Survey. RESULTS Sildenafil users reported an 88% increase in erectile function scores, 60% increase in overall sexual satisfaction and 36% increase in intercourse satisfaction related to the use of sildenafil (p <0.001). Of the respondents 38% indicated that using sildenafil had definitely improved quality of life. Likewise 29% of respondents indicated that using sildenafil had definitely improved the relationship with their partner. With sildenafil there was a statistically significant improvement in the scores of erectile and sexual function (p <0.001), sexual partner relationship (p = 0.007) and emotional well-being (p <0.001). In a multivariate model improved erectile function and sexual partner relationship were each significantly associated with improved emotional well-being (R2 = 0.20, p <0.001). CONCLUSIONS Sildenafil users reported significant improvements in erectile and sexual function that were associated with positive changes in emotional well-being and the sexual partner relationships with their sexual partner.

Association of Spinal Manipulative Therapy With Clinical Benefit and Harm for Acute Low Back Pain: Systematic Review and Meta-analysis

Importance Acute low back pain is common and spinal manipulative therapy (SMT) is a treatment option. Randomized clinical trials (RCTs) and meta-analyses have reported different conclusions about the effectiveness of SMT. Objective To systematically review studies of the effectiveness and harms of SMT for acute (⩽6 weeks) low back pain. Data Sources Search of MEDLINE, Cochrane Database of Systematic Reviews, EMBASE, and Current Nursing and Allied Health Literature from January 1, 2011, through February 6, 2017, as well as identified systematic reviews and RCTs, for RCTs of adults with low back pain treated in ambulatory settings with SMT compared with sham or alternative treatments, and that measured pain or function outcomes for up to 6 weeks. Observational studies were included to assess harms. Data Extraction and Synthesis Data extraction was done in duplicate. Study quality was assessed using the Cochrane Back and Neck (CBN) Risk of Bias tool. This tool has 11 items in the following domains: randomization, concealment, baseline differences, blinding (patient), blinding (care provider [care provider is a specific quality metric used by the CBN Risk of Bias tool]), blinding (outcome), co-interventions, compliance, dropouts, timing, and intention to treat. Prior research has shown the CBN Risk of Bias tool identifies studies at an increased risk of bias using a threshold of 5 or 6 as a summary score. The evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. Main Outcomes and Measures Pain (measured by either the 100-mm visual analog scale, 11-point numeric rating scale, or other numeric pain scale), function (measured by the 24-point Roland Morris Disability Questionnaire or Oswestry Disability Index [range, 0-100]), or any harms measured within 6 weeks. Findings Of 26 eligible RCTs identified, 15 RCTs (1711 patients) provided moderate-quality evidence that SMT has a statistically significant association with improvements in pain (pooled mean improvement in the 100-mm visual analog pain scale, −9.95 [95% CI, −15.6 to −4.3]). Twelve RCTs (1381 patients) produced moderate-quality evidence that SMT has a statistically significant association with improvements in function (pooled mean effect size, −0.39 [95% CI, −0.71 to −0.07]). Heterogeneity was not explained by type of clinician performing SMT, type of manipulation, study quality, or whether SMT was given alone or as part of a package of therapies. No RCT reported any serious adverse event. Minor transient adverse events such as increased pain, muscle stiffness, and headache were reported 50% to 67% of the time in large case series of patients treated with SMT. Conclusions and Relevance Among patients with acute low back pain, spinal manipulative therapy was associated with modest improvements in pain and function at up to 6 weeks, with transient minor musculoskeletal harms. However, heterogeneity in study results was large.

The top 10 things nephrologists wish every primary care physician knew.

Renal disease is commonly encountered by primary care physicians during their day-to-day visits with patients. Common renal disorders include hypertension, proteinuria, kidney stones, and chronic kidney disease. Despite their prevalence, many physicians may be unfamiliar with the diagnosis and initial treatment of these common renal disorders. Early recognition and intervention are important in slowing the progression of chronic kidney disease and preventing its complications. The evidence-based pearls in this article will help primary care physicians avoid common pitfalls in the recognition and treatment of such disorders and guide their decision to refer their patients to a specialist.

The Top 10 Things Foot and Ankle Specialists Wish Every Primary Care Physician Knew

Foot and ankle problems are common complaints of patients presenting to primary care physicians. These problems range from minor disorders, such as ankle sprains, plantar fasciitis, bunions, and iIngrown toenails, to more serious conditions such as Charcot arthropathy and Achilles tendon rupture. Early recognition and treatment of foot and ankle problems are imperative to avoid associated morbidities. Primary care physicians can address many of these complaints successfully but should be cognizant of which patients should be referred to a foot and ankle specialist to prevent common short-term and long-term complications. This article provides evidence-based pearls to assist primary care physicians in providing optimal care for their patients with foot and ankle complaints.

The top 10 infectious disease pitfalls that hospitalists can avoid

Infectious diseases are commonly encountered by hospitalists in their day-to-day care of patients. Challenges involved in caring for patients with infectious diseases include choosing the correct antibiotic, treating patients with a penicillin allergy, interpreting blood cultures, and caring for patients with human immunodeficiency virus (HIV). The evidence-based pearls in this article will help hospitalists avoid common pitfalls in the recognition and treatment of such disorders and guide their decision about when to consult an infectious diseases specialist.

The Top 10 Pulmonary Pearls for Primary Care Physicians

&NA; Pulmonary diseases are commonly encountered by primary care physicians in the outpatient setting. Despite their prevalence, many physicians may be unfamiliar with the diagnosis and appropriate management of these disorders. The evidence‐based pearls in this article will help primary care physicians navigate important topics in pulmonary medicine and guide their decision to refer their patients to a pulmonary specialist.

Spinal Manipulative Therapy for Low Back Pain—Reply

may therefore be ischemic in etiology. Conversely, not all patients included in the primary analysis and diagnosed as having MINS were certain to have had an ischemic etiology of myocardial injury. Therefore, it would be helpful to see additional details on the presumed provoking conditions of MINS (ie, hypoxia, anemia, hypotension, tachycardia) in this large perioperative cohort.2 Regardless, there is no question that chronic troponin elevation preceding the surgical stress and iatrogenic myocardial injury after cardioversion should be excluded from the cohort used to define MINS. Ultimately, a broadly applicable, inclusive definition of MINS based on highsensitivity cardiac biomarkers is an important first step toward developing guideline-based diagnostic and treatment strategies for patients with this common postoperative finding.3,4