Rema Ramakrishnan

Association of frailty with survival: a systematic literature review.

Frailty is a known risk factor for those aged 65 and over, and its prevalence increases with age. Definitions of frailty vary widely, and prevalence estimates are affected by the way frailty is defined. Systematic reviews have yet to examine the literature on the association between definitions of frailty and mortality. We examined the definitions and prevalence of frailty and its association with survival in older community-dwelling adults. We conducted a systematic review of observational population-based studies published in English. We calculated pooled prevalence of frailty with a random effects model. We identified 24 population-based studies that examined frailty in community-dwelling older adults. The pooled prevalence was 14% when frailty was defined as a phenotype exhibiting three or more of the following: weight loss, fatigue/exhaustion, weakness, low physical activity/slowness, and mobility impairment. The pooled prevalence was 24% when frailty was defined by accumulation of deficits indices that included up to 75 diseases and impairments. The prevalence of frailty increased with age and was greater in women and in African Americans. Frailty in older adults was associated with poor survival with a dose-responsive reduction in survival per increasing number of frailty criteria. Taking into account population prevalence and multivariate adjusted relative risks, we estimated that 3-5% of deaths among older adults could be delayed if frailty was prevented. Frailty is a prevalent and important geriatric syndrome associated with decreased survival. Geriatric assessment of frailty provides clinically important information about functional status and survival of older adults.

Physical Therapy Interventions for Knee Pain Secondary to Osteoarthritis: A Systematic Review

BACKGROUND Osteoarthritis is a leading cause of disability. Nonsurgical treatment is a key first step. PURPOSE Systematic literature review of physical therapy (PT) interventions for community-dwelling adults with knee osteoarthritis. DATA SOURCES MEDLINE, the Cochrane Library, the Physiotherapy Evidence Database, Scirus, Allied and Complementary Medicine, and the Health and Psychosocial Instruments bibliography database. STUDY SELECTION 193 randomized, controlled trials (RCTs) published in English from 1970 to 29 February 2012. DATA EXTRACTION Means of outcomes, PT interventions, and risk of bias were extracted to pool standardized mean differences. Disagreements between reviewers abstracting and checking data were resolved through discussion. DATA SYNTHESIS Meta-analyses of 84 RCTs provided evidence for 13 PT interventions on pain (58 RCTs), physical function (36 RCTs), and disability (29 RCTs). Meta-analyses provided low-strength evidence that aerobic (11 RCTs) and aquatic (3 RCTs) exercise improved disability and that aerobic exercise (19 RCTs), strengthening exercise (17 RCTs), and ultrasonography (6 RCTs) reduced pain and improved function. Several individual RCTs demonstrated clinically important improvements in pain and disability with aerobic exercise. Other PT interventions demonstrated no sustained benefit. Individual RCTs showed similar benefits with aerobic, aquatic, and strengthening exercise. Adverse events were uncommon and did not deter participants from continuing treatment. LIMITATION Variability in PT interventions and outcomes measures hampered synthesis of evidence. CONCLUSION Low-strength evidence suggested that only a few PT interventions were effective. Future studies should compare combined PT interventions (which is how PT is generally administered for pain associated with knee osteoarthritis). PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality.

Not just specific diseases: Systematic review of the association of geriatric syndromes with hospitalization or nursing home admission

To examine the association between geriatric syndromes with hospitalization or nursing home admission, we reviewed studies that examined hospitalization and nursing home admission in community-dwelling older adults with multiple morbidities, cognitive impairment, frailty, disability, sarcopenia, malnutrition, impaired homeostasis, and chronic inflammation. Studies published in English language were identified through MEDLINE (1990 through April 2010), Cochrane databases, the Centers for Disease Control and Prevention website and manual searches of reference lists from relevant publications. The study had to include general (non-disease specific) populations of adults aged 65 years or older. Using a standardized protocol, two investigators independently abstracted information on participant characteristics and adjusted measures of the association. Studies that controlled for the presence of specific diseases were further identified and analyzed. When the syndrome examined was similar from different studies, we computed the pooled risk estimates using a random-effects model. We assessed the strength of evidence following the recommended guidelines. We identified 47 eligible articles from 6 countries. Multiple morbidity, frailty, and disabilities were associated with hospitalization and nursing home admission (moderate evidence). Cognitive impairment was associated with hospitalization (low evidence) and nursing home admission (moderate evidence). Among these studies, 20 articles controlled for specific diseases. Limited evidence suggested that these geriatric syndromes are associated with hospitalization and institutionalization after controlling for the presence of specific diseases. We conclude that geriatric syndromes are associated with risk of hospitalization or nursing home admission. Efforts to prevent hospitalization or nursing home admission should target strategies to prevent and manage these syndromes.

Comparing Bayesian and Frequentist Approaches for Multiple Outcome Mixed Treatment Comparisons

Objectives. Bayesian statistical methods are increasingly popular as a tool for meta-analysis of clinical trial data involving both direct and indirect treatment comparisons. However, appropriate selection of prior distributions for unknown model parameters and checking of consistency assumptions required for modeling remain particularly challenging. We compared Bayesian and traditional frequentist statistical methods for mixed treatment comparisons with multiple binary outcomes. Data. We searched major electronic bibliographic databases, Food and Drug Administration reviews, trial registries, and research grant databases up to December 2011 to find randomized studies published in English that examined drugs for female urgency urinary incontinence (UI) on continence, improvement in UI, and treatment discontinuation due to harm. Methods. We describe and fit fixed and random effects models in both Bayesian and frequentist statistical frameworks. In a hierarchical model of 8 treatments, we separately analyze 1 safety and 2 efficacy outcomes. We produce Bayesian and frequentist treatment ranks and odds ratios across all drug v placebo comparisons, as well as Bayesian probabilities that each drug is best overall through a weighted scoring rule that trades off efficacy and safety. Results. In our study, Bayesian and frequentist random effects models generally suggest the same drugs as most attractive, although neither suggests any significant differences between drugs. However, the Bayesian methods more consistently identify one drug (propiverine) as best overall, produce interval estimates that are generally better at capturing all sources of uncertainty in the data, and also permit attractive “rankograms” that visually capture the probability that each drug assumes each possible rank. Conclusions. Bayesian methods are more flexible and their results more clinically interpretable, but they require more careful development and specialized software.

Assessing equivalence and noninferiority

OBJECTIVE For systematic reviews, no guidance exists for what review methods support valid conclusions of equivalence (EQ) and noninferiority (NI). To provide such guidance, we convened a workgroup of 13 experienced systematic reviewers from seven evidence-based practice centers (EPCs) and the Agency for Healthcare Research and Quality (AHRQ). STUDY DESIGN AND SETTING The Lead EPC first performed two methods projects intended to assist the workgroup in clarifying the context, prioritizing the issues, targeting the scope, and summarizing the state of the art. RESULTS Based on expert opinion, we devised guidance in four areas: 1) Unique risk of bias issues for trials self-identifying as EQ-NI trials; 2) Setting the reviewers minimum important difference; 3) Analytic foundations for concluding EQ or NI; and 4) Language considerations when concluding EQ or NI. CONCLUSION This article summarizes the main recommendations, and the full guidance chapter appears on the AHRQ Web site.

Prevalence, Correlates, and Outcomes of Omphalocele in the United States, 1995-2005.

OBJECTIVE: To examine the trends in the prevalence, epidemiologic correlates, and 1-year survival of omphalocele using 1995–2005 data from the National Birth Defects Prevention Network in the United States. METHODS: We examined 2,308 cases of omphalocele over 11 years from 12 state population-based birth defects registries. We used Poisson regression to estimate prevalence and risk factors for omphalocele and Kaplan-Meier survival curves and Cox proportional hazards regression to estimate survival patterns and hazard ratios, respectively, to examine isolated compared with nonisolated cases. RESULTS: Birth prevalence of omphalocele was 1.92 per 10,000 live births with no consistent trend over time. Neonates with omphalocele were more likely to be male (prevalence ratio 1.22, 95% confidence interval [CI] 1.12–1.34), born to mothers 35 years of age or older (prevalence ratio 1.77, 95% CI 1.54–2.04) and younger than 20 years (prevalence ratio 1.34, 95% CI 1.14–1.56), and of multiple births (prevalence ratio 2.22, 95% CI 1.85–2.66). The highest proportion of neonates with omphalocele had congenital heart defects (32%). The infant mortality rate was 28.7%, with 75% of those occurring in the first 28 days. The best survival was for isolated cases and the worst for neonates with chromosomal defects (hazard ratio 7.75, 95% CI 5.40–11.10) and low-birth-weight neonates (hazard ratio 7.51, 95% CI 5.86–9.63). CONCLUSION: Prevalence of omphalocele has remained constant from 1995 to 2005. Maternal age (younger than 20 years and 35 years or older), multiple gestation, and male sex are important correlates of omphalocele, whereas co-occurrence with chromosomal defects and very low birth weight are consistent determinants of 1-year survival among these neonates. LEVEL OF EVIDENCE: II

The Association between Maternal Perception of Obstetric and Pediatric Care Providers’ Attitudes and Exclusive Breastfeeding Outcomes:

Background: Exclusive breastfeeding is recommended for 6 months. Successful breastfeeding requires support from family members, peers, and health care professionals. Objective: This study aimed to determine the association between maternal perception of the attitudes of obstetric and pediatric care providers about infant feeding during the neonatal period and exclusive breastfeeding at 1, 3, and 6 months. Methods: The study sample consisted of 1602 women from the Infant Feeding Practices Study II (2005-2007), a longitudinal study of women in the United States. Analyses included chi-square and Fisher’s exact tests and logistic regression models. Results: Mothers who perceived that the obstetric care provider favored exclusive breastfeeding were significantly more likely to exclusively breastfeed their infants at 1 and 3 months (odds ratio [OR] = 1.73, 95% confidence interval [CI], 1.33-2.24; and OR = 1.41, 95% CI, 1.09-1.80, respectively) as compared to mothers who perceived that the obstetric care provider was neutral about the type of infant feeding. Similarly, mothers who perceived that the pediatric care provider favored exclusive breastfeeding had higher odds of exclusively breastfeeding their infants at 1 and 3 months (OR = 1.53, 95% CI, 1.17-1.99; and OR = 1.51, 95% CI, 1.17-1.95, respectively) as compared to mothers who perceived that the pediatric care provider was neutral about the type of infant feeding. The association was no longer significant at 6 months. Conclusion: Maternal perception of obstetric and pediatric care providers’ preference for exclusive breastfeeding during the neonatal period is associated with exclusive breastfeeding until 3 months.

Episodic Migraines in Children Limited Evidence on Preventive Pharmacological Treatments

The authors conducted a systematic literature review of preventive pharmacological treatments for episodic childhood migraines searching several databases through May 20, 2012. Episodic migraine prevention was examined in 24 publications of randomized controlled trials that enrolled 1578 children in 16 nonrandomized studies. Single randomized controlled trials provided low-strength evidence that propranolol would result in complete cessation of migraine attacks in 713 per 1000 children treated (95% confidence interval, 452-974); trazodone and nimodipine decreased migraine days, while topiramate, divalproex, and clonidine were no more effective than placebo in preventing migraines. Migraine prevention with multidisciplinary drug management was not sustained at 6 months. Divalproex resulted in treatment discontinuation due to adverse effects, and topiramate increased the risk of paresthesia, upper respiratory tract infection, and weight loss. Long-term preventive benefits and improvement in disability and quality of life are unknown. No studies examined quality of life or provided evidence for individualized treatment decisions.

Immigrant Health through the Lens of Home Visitors, Supervisors, and Administrators: The Florida Maternal, Infant, and Early Childhood Home Visiting Program

OBJECTIVE The Florida Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program aims to minimize the occurrence of adverse maternal and child health outcomes for mothers deemed at-risk during pregnancy or shortly after childbirth. This study sought to understand the needs of and challenges faced by immigrant families in accessing health care through the perspective of Florida MIECHV home visitors, supervisors, and administrators. DESIGN AND SAMPLE In this exploratory qualitative study, focus groups were held at each of the Florida MIECHV-funded program sites with a total of 81 MIECHV staff to discuss how the program addresses a range of participant needs. MEASURES Data were collected through 32 semi-structured focus groups. Transcripts were analyzed using a hybrid approach entailing the development of an a priori codebook and thematic analysis. RESULTS Staff from eight of the 11 programs described social and physical isolation and economic hardship faced by immigrant families enrolled in their programs, resulting in barriers to needed health care and social services. CONCLUSIONS Home visitors in the Florida MIECHV program served as trusted confidants that helped families navigate social services. Future research should focus on the impact that home visiting has on immigrant health and whether this impact is maintained over time.

Demographic and socioeconomic factors influencing disparities in prevalence of alcohol-related injury among underserved trauma patients in a safety-net hospital

BACKGROUND Alcohol-related trauma remains high among underserved patients despite ongoing preventive measures. Geographic variability in prevalence of alcohol-related injury has prompted reexamination of this burden across different regions. We sought to elucidate demographic and socioeconomic factors influencing the prevalence of alcohol-related trauma among underserved patients and determine alcohol effects on selected outcomes. METHODS A retrospective analysis examined whether patients admitted to a suburban trauma center differed according to their blood alcohol concentration (BAC) on admission. Patients were stratified based on their BAC into four categories (undetectable BAC, BAC 1-99mg/dL, BAC 100-199mg/dL, and BAC ≥ 200mg/dL). T-tests and X2 tests were used to detect differences between BAC categories in terms of patient demographics and clinical outcomes. Multivariate linear and logistic regressions were used to investigate the association between patient variables and selected outcomes while controlling for confounders. RESULTS One third of 738 patients analyzed were BAC-positive, mean (SD) BAC was 211.4 (118.9) mg/dL, 80% of BAC-positive patients had levels ≥ 100mg/dL. After risk adjustments, the following patient characteristics were predictive of having highly elevated BAC (≥200mg/dL) upon admission to the Trauma Center; Hispanic patients (adjusted odds ratio (OR)=1.91, 95% confidence interval (CI): 1.14-3.21), unemployment (OR=1.74, 95% CI: 1.09-2.78), Medicaid beneficiaries (OR=3.59, 95% CI: 1.96-6.59), and uninsured patients (OR=2.86, 95% CI: 1.60-5.13). Patients with BAC of 100-199mg/dL were likely to be more severely injured (P=0.016) compared to undetectable-BAC patients. There was no association between being intoxicated, and being ICU-admitted or having differences in length of ICU or hospital stay. CONCLUSION Demographic and socioeconomic factors underlie disparities in the prevalence of alcohol-related trauma among underserved patients. These findings may guide targeted interventions toward specific populations to help reduce the burden of alcohol-related injury.