Peggy Nygren

Screening for Speech and Language Delay in Preschool Children: Systematic Evidence Review for the US Preventive Services Task Force

BACKGROUND. PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Published in the public domain by the American Academy of Pediatrics.Speech and language development is a useful indicator of a childs overall development and cognitive ability and is related to school success. Identification of children at risk for developmental delay or related problems may lead to intervention services and family assistance at a young age, when the chances for improvement are best. However, optimal methods for screening for speech and language delay have not been identified, and screening is practiced inconsistently in primary care. PURPOSE. We sought to evaluate the strengths and limits of evidence about the effectiveness of screening and interventions for speech and language delay in preschool-aged children to determine the balance of benefits and adverse effects of routine screening in primary care for the development of guidelines by the US Preventive Services Task Force. The target population includes all children up to 5 years old without previously known conditions associated with speech and language delay, such as hearing and neurologic impairments. METHODS. Studies were identified from Medline, PsycINFO, and CINAHL databases (1966 to November 19, 2004), systematic reviews, reference lists, and experts. The evidence review included only English-language, published articles that are available through libraries. Only randomized, controlled trials were considered for examining the effectiveness of interventions. Outcome measures were considered if they were obtained at any time or age after screening and/or intervention as long as the initial assessment occurred while the child was ≤5 years old. Outcomes included speech and language measures and other functional and health outcomes such as social behavior. A total of 745 full-text articles met our eligibility criteria and were reviewed. Data were extracted from each included study, summarized descriptively, and rated for quality by using criteria specific to different study designs developed by the US Preventive Services Task Force. RESULTS. The use of risk factors for selective screening has not been evaluated, and a list of specific risk factors to guide primary care physicians has not been developed or tested. Sixteen studies about potential risk factors for speech and language delay in children enrolled heterogeneous populations, had dissimilar inclusion and exclusion criteria, and measured different risk factors and outcomes. The most consistently reported risk factors included a family history of speech and language delay, male gender, and perinatal factors. Other risk factors reported less consistently included educational levels of the mother and father, childhood illnesses, birth order, and family size. The performance characteristics of evaluation techniques that take ≤10 minutes to administer were described in 24 studies relevant to screening. Studies that were rated good to fair quality reported wide ranges of sensitivity and specificity when compared with reference standards (sensitivity: 17–100%; specificity: 45–100%). Most of the evaluations, however, were not designed for screening purposes, the instruments measured different domains, and the study populations and settings were often outside of primary care. No “gold standard” has been developed and tested for screening, reference standards varied across studies, few studies compared the performance of ≥2 screening techniques in 1 population, and comparisons of a single screening technique across different populations are lacking. Fourteen good- and fair-quality randomized, controlled trials of interventions reported significantly improved speech and language outcomes compared with control groups. Improvement was demonstrated in several domains including articulation, phonology, expressive language, receptive language, lexical acquisition, and syntax among children in all age groups studied and across multiple therapeutic settings. Improvement in other functional outcomes such as socialization skills, self-esteem, and improved play themes were demonstrated in some, but not all, of the 4 studies that measured them. In general, studies of interventions were small and heterogeneous, may be subject to plateau effects, and reported short-term outcomes based on various instruments and measures. As a result, long-term outcomes are not known, interventions could not be compared directly, and generalizability is questionable. Conclusions. Use of risk factors to guide selective screening is not supported by studies. Several aspects of screening have been inadequately studied to determine optimal methods, including which instrument to use, the age at which to screen, and which interval is most useful. Trials of interventions demonstrate improvement in some outcome measures, but conclusions and generalizability are limited. Data are not available addressing other key issues including the effectiveness of screening in primary care settings, role of enhanced surveillance by primary care physicians before referral for diagnostic evaluation, non–speech and language and long-term benefits of interventions, and adverse effects of screening and interventions.

Screening Women and Elderly Adults for Family and Intimate Partner Violence: A Review of the Evidence for the U.S. Preventive Services Task Force

As many as 1 to 4 million women are physically, sexually, or emotionally abused by their intimate partners each year in the United States (1, 2), and 31% of all women report abuse in their lifetime (3). Prevalence rates of abuse in clinical samples range from 4% to 44% within the past year and from 21% to 55% over a lifetime (4-14). The incidence of acute cases in emergency care settings ranges from 2% to 7% (15). Approximately 20% of female teenage survey respondents reported being physically or sexually abused by a dating partner (16). Although women also commit violence against men, women are 7 to 14 times more likely to sustain severe physical injury from an assault by an intimate partner (17). Approximately 551 000 older adults in domestic settings were abused or neglected in 1996 (18). A random-sample survey of a community population indicated a prevalence rate of 32 per 1000 for physical violence, verbal aggression, and neglect (19). Complicating these estimates, however, is the difficulty in defining and quantifying elder abuse. Abuse of elderly persons takes many forms, including physical, sexual, psychological, and financial exploitation as well as neglect (20). Available data indicate that the highest rates of elder abuse are among women and those 80 years of age and older (18). In 90% of cases, the perpetrator is a family member, most often an adult child or spouse (18). Many health problems are associated with abuse and neglect at all ages. These include repercussions of acute trauma, including death and unwanted pregnancy, as well as long-term physical and mental problems, such as depression, post-traumatic stress disorder, somatization, suicide, and substance abuse (16, 21-30). Children who witness intimate partner violence are at risk for developmental delay, school failure, psychiatric disorders (31, 32), and violence against others (33). Physician and nursing organizations consider the clinicians role in identification and intervention to be a professional responsibility (34, 35). Reporting child and elder abuse to protective services is mandatory in almost all states; 4 states (California, Colorado, Rhode Island, and Kentucky) have laws requiring mandatory reporting of intimate partner violence. Hospitals are also required to address abuse in order to maintain accreditation (36). Whether screening leads to a decline in abuse is unknown. In the mid-1990s, after several medical organizations recommended screening for intimate partner abuse, rates of abuse decreased (37). A systematic review reported that most studies of screening for intimate partner violence in health care settings found that screening detected more abused women than no screening (38). Surveys indicate that 43% to 85% of female respondents consider screening in health care settings acceptable, although only one third of physicians and half of emergency department nurses favored screening (38). The evidence on how to screen and effectively intervene once problems are identified is limited, and few clinicians routinely screen patients who do not have apparent injuries (39-44). In 1996, the U.S. Preventive Services Task Force (USPSTF) concluded that there was insufficient evidence to recommend for or against the use of specific screening instruments to detect family or intimate partner violence, although including questions about abuse in the routine history could be recommended on the basis of prevalence of abuse among adult women and the potential value of the information to clinicians (45). This report is an update on the current literature on family and intimate partner violence. It focuses on studies of the performance of screening instruments designed for the clinical setting and the effectiveness of clinical-based interventions for women and elderly adults. A separate report on screening for family violence in children is available elsewhere (46). Methods The analytic framework and key questions guiding this review are detailed in the Figure. Relevant studies were identified from multiple searches of MEDLINE (1966 to December 2002), PsycINFO (1984 to December 2002), CINAHL (1982 to December 2002), Health & Psychosocial Instruments (1985 to December 2002), AARP Ageline (1978 to December 2002), and the Cochrane Controlled Trials Register (Appendix). Additional articles were obtained by reviewing 2 recent systematic reviews (38, 47), by reviewing reference lists of pertinent studies, and by consulting experts. Figure. Analytic framework and key questions ( KQs ). We defined screening as an assessment of current harm or risk for harm from family and intimate partner violence in asymptomatic persons in a health care setting. Universal screening assesses everyone; selective screening assesses only those who meet specific criteria. The target populations for this review were women and elderly victims of abuse from family members, intimate partners, caretakers, or others with similar relationships. The USPSTF focused this review on these populations because they are the largest at-risk groups in general primary care settings. Studies included in this review had English-language abstracts; were applicable to U.S. clinical practice; described abuse and violence against women or elderly adults; were conducted in or linked to primary care (for example, family practice or general internal medicine), obstetrics and gynecology, or emergency department settings; and included a physician or other health care provider in the process of assessment or intervention. We excluded studies about patients presenting with trauma. All eligible studies were reviewed, including those published before the 1996 USPSTF recommendation. Assessment studies were included if they evaluated the performance of verbal or written questionnaires or other assessment procedures, such as physical examinations, that were brief and applicable to the primary care setting. Included studies described the study sample, the screening instrument or procedure, the abuse or neglect outcome, and the collection of data. Outcomes included indicators of physical abuse, neglect, emotional abuse, or sexual abuse and any reported related health outcomes (for example, depression). Intervention studies were included if they measured the effectiveness of an intervention in reducing harm from family and intimate partner violence compared with nonintervention or usual care groups. We excluded studies that tested the effectiveness of interventions to educate health care professionals about family violence or to increase screening rates in institutions. We also excluded studies about mandatory reporting laws, descriptions of programs, the accuracy of physician diagnosis and reporting of abuse, and physician factors related to reporting. From each included study, we abstracted the study design, number of participants, setting, length and type of interventions, length of follow-up, outcomes, methods of outcome measurement, and study duration, among other variables. Two reviewers independently rated each studys quality using criteria specific to different study designs developed by the USPSTF (Appendix) (48). When reviewers disagreed, a final score was reached through consensus. This research was funded by the Agency for Healthcare Research and Quality under a contract to support the work of the USPSTF. Agency staff and Task Force members participated in the initial design of the study and reviewed interim analyses and the final manuscript. Additional reports were distributed for review to content experts and revised accordingly before preparation of this manuscript. The authors are responsible for the content of the manuscript and the decision to submit it for publication. Data Synthesis Intimate Partner Violence against Women Screening Of 806 abstracts identified by database searches, 14 met inclusion criteria. These included 6 studies that compared one instrument with another, 3 that compared an instrument with a directed interview, 2 that measured interrater reliability or internal consistency, and 3 that compared methods of administration. None evaluated the performance of a screening instrument or procedure by using verified abuse outcomes. Screening instruments are described in Appendix Figures 1 and 2 and Appendix Tables 1 and 2 (49-61). Appendix Figure 1. Screening instruments for intimate partner violence against women Appendix Figure 2. Screening instruments for elder abuse and neglect. Six studies compared brief screening instruments with previously validated instruments and were rated as good or fair in quality (Table 1) (15, 53, 54, 56, 57, 62). Brief instruments were generally correlated with longer instruments and in some cases performed better. Table 1. Studies of Screening Instruments about Intimate Partner Violence against Women The Hurt, Insulted, Threatened, or Screamed at (HITS) instrument includes 4 questions (54). When administered to 259 women in family practice clinics, it demonstrated fair internal consistency (Cronbach statistic = 0.80), and its results correlated with the previously validated 19-item Conflict Tactics Scales (CTS) (r = 0.85). In urban emergency department settings, the Partner Violence Screen (PVS), consisting of 3 questions, was compared with the 30-item Index of Spouse Abuse (ISA) (sensitivity, 64.5%; specificity, 80.3%) and the Conflict Tactics Scales (sensitivity, 71.4%; specificity, 84.4%) (53). However, the validity of the Conflict Tactics Scales may not have been tested sufficiently to qualify it as a gold standard in these studies. A study of 1152 predominantly African-American women presenting for care at university-affiliated family practice clinics found that the 10-item Womens Experience with Battering (WEB) Scale had a higher detection rate (16%) than the 15-item Index of Spouse AbusePhysical Scale (10%) (56). Another trial studying predominantly white women in family practice clinics found that the 8-item Woman Abuse Screening Tool

Systematic review of the incidence and consequences of uterine rupture in women with previous caesarean section.

Abstract Objective To evaluate the incidence and consequences of uterine rupture in women who have had a delivery by caesarean section. Design Systematic review. Data sources Medline, HealthSTAR, Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, National Centre for Reviews and Dissemination, reference lists, and national experts. Studies in all languages were eligible if published in full. Review methods Methodological quality was evaluated for each study by using criteria from the United States Preventive Services Task Force and the National Health Service Centre for Reviews and Dissemination. Uterine rupture was categorised as asymptomatic or symptomatic. Results We reviewed 568 full text articles to identify 71 potentially eligible studies, 21 of which were rated at least fair in quality. Compared with elective repeat caesarean delivery, trial of labour increased the risk of uterine rupture by 2.7 (95% confidence interval 0.73 to 4.73) per 1000 cases. No maternal deaths were related to rupture. For women attempting vaginal delivery, the additional risk of perinatal death from rupture of a uterine scar was 1.4 (0 to 9.8) per 10 000 and the additional risk of hysterectomy was 3.4 (0 to 12.6) per 10 000. The rates of asymptomatic uterine rupture in trial of labour and elective repeat caesarean did not differ significantly. Conclusions Although the literature on uterine rupture is imprecise and inconsistent, existing studies indicate that 370 (213 to 1370) elective caesarean deliveries would need to be performed to prevent one symptomatic uterine rupture.

Physicians, patients, and the electronic health record: an ethnographic analysis.

PURPOSE Little is known about the effects of the electronic health record (EHR) on physician-patient encounters. The objectives of this study were to identify the factors that influence the manner by which physicians use the EHR with patients. METHODS This ethnographic study included 4 qualitative components: 80 hours of participant observation in 4 primary care offices in the Pacific Northwest; individual interviews with 52 patients, 12 office staff members, 23 physicians, and 1 nurse-practitioner; videotaped reviews of 29 clinical encounters; and 5 focus-group interviews with physicians and computer advocates. The main outcome measures were factors that influence how physicians use the EHR. Researchers qualitatively derived these factors through serial reviews of data. RESULTS This study identified 14 factors that influence how EHRs are used and perceived in medical practice today. These factors were categorized into 4 thematic domains: (1) spatial—effect of the physical presence and location of EHRs on interactions between physicians and patients; (2) relational—perceptions of physicians and patients about the EHR and how those perceptions affected its use; (3) educational—issues of developing physicians’ proficiency with and improving patients’ understandings about EHR use; and (4) structural—institutional and technological forces that influence how physicians perceived their use of EHR. CONCLUSIONS This study found that the introduction of EHRs into practice influences multiple cognitive and social dimensions of the clinical encounter. It brings into focus important questions that through further inquiry can determine how to make best use of the EHR to enhance therapeutic relationships.

Vaginal birth after cesarean: New insights on maternal and neonatal outcomes

OBJECTIVE: To systematically review the evidence about maternal and neonatal outcomes relating to vaginal birth after cesarean (VBAC). DATA SOURCES: Relevant studies were identified from multiple searches of MEDLINE, DARE, and the Cochrane databases (1980 to September 2009) and from recent systematic reviews, reference lists, reviews, editorials, Web sites, and experts. METHODS OF STUDY SELECTION: Inclusion criteria limited studies to the English-language and human studies conducted in the United States and developed countries specifically evaluating birth after previous cesarean delivery. Studies focusing on high-risk maternal or neonatal conditions, including breech vaginal delivery, or fewer than 10 patients were excluded. Poor-quality studies were not included in analyses. TABULATION, INTEGRATION, AND RESULTS: We identified 3,134 citations and reviewed 963 articles for inclusion; 203 articles met the inclusion criteria and were quality rated. Overall rates of maternal harms were low for both trial of labor and elective repeat cesarean delivery. Although rare in both elective repeat cesarean delivery and trial of labor, maternal mortality was significantly increased for elective repeat cesarean delivery at 0.013% compared with 0.004% for trial of labor. The rates of maternal hysterectomy, hemorrhage, and transfusions did not differ significantly between trial of labor and elective repeat cesarean delivery. The rate of uterine rupture for all women with prior cesarean was 0.30%, and the risk was significantly increased for trial of labor (0.47% compared with 0.03% for elective repeat cesarean delivery). Perinatal mortality was also significantly increased for trial of labor (0.13% compared with 0.05% for elective repeat cesarean delivery). CONCLUSION: Overall the best evidence suggests that VBAC is a reasonable choice for the majority of women. Adverse outcomes were rare for both elective repeat cesarean delivery and trial of labor. Definitive studies are lacking to identify patients who are at greatest risk for adverse outcomes.

Universal Newborn Hearing Screening: Systematic Review to Update the 2001 US Preventive Services Task Force Recommendation

OBJECTIVE. This review is an update for the US Preventive Services Task Force on universal newborn hearing screening to detect moderate-to-severe permanent, bilateral congenital hearing loss. We focus on 3 key questions: (1) Among infants identified by universal screening who would not be identified by targeted screening, does initiating treatment before 6 months of age improve language and communication outcomes? (2) Compared with targeted screening, does universal screening increase the chance that treatment will be initiated by 6 months of age for infants at average risk or for those at high risk? (3) What are the adverse effects of screening and early treatment? METHODS. Medline and Cochrane databases were searched to identify articles published since the 2002 recommendation. Data from studies that met inclusion criteria were abstracted, and studies were rated for quality with predetermined criteria. RESULTS. A good-quality retrospective study of children with hearing loss indicates that those who had early versus late confirmation and those who had undergone universal newborn screening versus none had better receptive language at 8 years of age but not better expressive language or speech. A good-quality nonrandomized trial of a large birth cohort indicates that infants identified with hearing loss through universal newborn screening have earlier referral, diagnosis, and treatment than those not screened. These findings are corroborated by multiple descriptive studies of ages of referral, diagnosis, and treatment. Usual parental reactions to an initial nonpass on a hearing screen include worry, questioning, and distress that resolve for most parents. Cochlear implants have been associated with higher risks for bacterial meningitis in young children. CONCLUSIONS. Children with hearing loss who had universal newborn hearing screening have better language outcomes at school age than those not screened. Infants identified with hearing loss through universal screening have significantly earlier referral, diagnosis, and treatment than those identified in other ways.

Systematic Review: Comparative Effectiveness of Medications to Reduce Risk for Primary Breast Cancer

Nelson and colleagues reviewed trials and observational studies to summarize the benefits and harms of tamoxifen citrate, raloxifene, and tibolone in reducing the risk for primary breast cancer in ...

Screening children for family violence: a review of the evidence for the US Preventive Services Task Force

BACKGROUND We wanted to evaluate the benefits and harms of screening children in primary health care settings for abuse and neglect resulting from family violence by examining the evidence on the performance of screening instruments and the effectiveness of interventions. METHODS We searched for relevant studies in MEDLINE, PsycINFO, CINAHL, ERIC, Cochrane Controlled Trials Register, and reference lists. English language abstracts with original data about family violence against children focusing on screening and interventions initiated or based in health care settings were included. We extracted selected information about study design, patient populations and settings, methods of assessment or intervention, and outcome measures, and applied a set of criteria to evaluate study quality. RESULTS All instruments designed to screen for child abuse and neglect were directed to parents, particularly pregnant women. These instruments had fairly high sensitivity but low specificity when administered in high-risk study populations and have not been widely tested in other populations. Randomized controlled trials of frequent nurse home visitation programs beginning during pregnancy that address behavioral and psychological factors indicated improved abuse measures and outcomes. No studies were identified about interventions in older children or harms associated with screening and intervention. CONCLUSIONS No trials of the effectiveness of screening in a health care setting have been published. Clinician referrals to nurse home visitation during pregnancy and in early childhood may reduce abuse in selected populations. There are no studies about harms of screening and interventions.

Screening for Elevated Lead Levels in Childhood and Pregnancy: An Updated Summary of Evidence for the US Preventive Services Task Force

BACKGROUND. In 1996, the US Preventive Services Task Force provided recommendations for routine screening of asymptomatic children and pregnant women for elevated blood lead levels. This review updates the evidence for the benefits and harms of screening and intervention for elevated blood lead in asymptomatic children and pregnant women. METHODS. We searched Medline, reference lists of review articles, and tables of contents of leading pediatric journals for studies published in 1995 or later that contained new information about the prevalence, diagnosis, natural course, or treatment of elevated lead levels in asymptomatic children aged 1 to 5 years and pregnant women. RESULTS. The prevalence of elevated blood lead levels among children and women in the United States, like that in the general population, continues to decline sharply, primarily because of marked reductions in environmental exposure, but still varies substantially among different communities and populations. Similar to the findings in 1996, our searches did not identify direct evidence from controlled studies that screening children for elevated blood lead levels results in improved health outcomes, and there was no direct evidence identified from controlled studies that screening improves pregnancy or perinatal outcomes. No new relevant information regarding the accuracy of screening for lead toxicity was identified during the update, and we did not identify evidence that demonstrates that universal screening for blood lead results in better clinical outcomes than targeted screening. Substantial new relevant information regarding the adverse effects of screening and interventions was not identified. CONCLUSIONS. There is no persuasive evidence that screening for elevated lead levels in asymptomatic children will improve clinical outcomes. For those children who are screened and found to have elevated levels, there is conflicting evidence demonstrating the clinical effectiveness of early detection and intervention.