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STUDENT DIGITAL NEWSLETTER ALAGAPPA INSTITUTIONS |
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S. Munir Alam, PhD
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Administering doses of a multidose vaccine at intervals shorter than those recommended in the childhood and adolescent immunization schedule might be necessary in circumstances in which an infant or child is behind schedule and needs to be brought up or for international travel muscle spasms 8 weeks pregnant order 30 mg nimotop fast delivery, measles vaccine may be given as early as 6 months of age muscle relaxer 75 nimotop 30 mg on-line. However spasms hindi meaning order nimotop 30 mg with visa, if a measles-containing vaccine is administered before 12 months of age spasms going to sleep buy nimotop 30 mg lowest price, the dose is not counted toward the 2-dose measles vaccine series. A third dose of a measles-containing vaccine is indicated at 4 through 6 years of age but can be administered as early as 4 weeks after the second dose (see Measles, p 535). If the child is known to the clinician and followup can be ensured, rescheduling the child for immunization closer to the recommended interval is preferred. If the parent or child is not known to the clinician or follow-up cannot be ensured (eg, habitually misses appointments), administration of the vaccine at that visit rather than rescheduling the child for a later visit is preferable. Vaccine doses administered 4 days or fewer before the minimum interval or age can be counted as valid. Doses administered 5 days or more before the minimum interval or age should not be counted as valid doses and should be repeated as age appropriate. This 4-day recommendation does not apply to rabies vaccine because of the immunization schedule (http:/ /redbook. Interchangeability of Vaccine Products Similar vaccines made by different manufacturers can differ in the number and amount agents, thereby eliciting different immune responses. When possible, effort should be made to complete a series with vaccine made by the same manufacturer. Although data documenting the effects of interchangeability are limited, most experts have considered vaccines interchangeable when administered according to their recommended indications. Because simultaneous administration of routinely recommended vaccines is not known to alter the effectiveness or safety of any of the recommended childhood vaccines, simultaneous administration of all vaccines that are appropriate for the age and immunization status of the recipient is recommended. Combination vaccines can be administered instead of separately nation vaccines licensed for use in the United States. When patients have received the recommended immunizations for some of the components in a combination vaccine, administering the extra antigen(s) in the combination vaccine is permissible if they are not contraindicated ( Lapsed Immunizations or addition of doses to the series for any vaccine in the recommended schedule. A computer-based tool is available for downloading and can be used to determine which vaccines a child 6 years or younger needs according to the childhood immunization schedule, including timing of missed or skipped vaccines ( In general, initiation of revaccination with an ageappropriate schedule of pertussis, diphtheria, and tetanus toxoid-containing vaccine is if a severe local reaction occurs. Active Immunization of People Who Recently Received Immune Globulin and Other Blood Products Live-virus vaccines may have diminished immunogenicity when given within 2 weeks ulins following intramuscular, intravenous, or subcutaneous administration). In particular, of immune response to rubella vaccine also has been demonstrated, but the effect on response to mumps or varicella vaccines is not known. Vaccines should be administered at a separate anatomic site from that of eases in Section 3. Testing for Mycobacterium tuberculosis Infection Testing for Mycobacterium tuberculosis tering live-virus vaccines. Inactivated vaccines, polysaccharide vaccines, and recombinant or subunit vaccines and toxoids do not interfere with clinical Record Keeping and Immunization Information Systems the National Vaccine Advisory Committee in 1993 recommended a set of standards to improve immunization practices for health care professionals serving children, and revised the standards in 2002. In addition, the standards also recommend use of tracking systems to provide reminder/recall notices to nonminor patients, parents or legal guardians, and physicians when immunizations are due or overdue. The format tion and, if maintained in a hard-copy health record, should be kept as a single summary sheet of all immunizations administered. Records of children whose immunizations have been delayed or missed should be the National Childhood Vaccine Injury Act of 1986 as well as data recommended by Discussing Vaccines With Patients and Parents (p 7). Highly effective vaccines have dramatically reduced the threat of infectious diseases, and because of this success some people now worry more about potential vaccine adverse effects than the illnesses vaccines prevent. Recommendations are made to maximize protection and minimize risk by providing speto vaccination. The occurrence of an adverse event following vaccination does not mean the vaccine tions for adverse events following immunization to be used in vaccine safety surveillance and research. The Brighton Collaboration provides guidelines for collecting, analyzing, and presenting vaccine safety data, which facilitates sharing and comparison of vaccine data among professionals working in the area of vacof progress, can be found online (https:/ /brightoncollaboration. Although rare, a causal link with a live-virus vaccine may be established if the vaccine-type virus ciency). Clustering in time of unusual adverse events following vaccination may suggest a following immunization include clinical syndromes that also occur in the absence of vaccomparing the incidence of the event in vaccinees to nonvaccinees or the incidence of the with the incidence in other timeframes. During the years 2001-2004, the Immunization Safety Review Committee evaluated 8 existing and emerging vaccine safety concerns. One of these reports examined hypotheses about associations between vaccines and autism. This review determined that the childhood immunization schedule is safe and that following the complete childhood immunization schedule is strongly associated with reducing vaccine-preventable diseases. The poliovirus, hepatitis A, hepatitis B, pertussis, diphtheria, tetanus, rotavirus, Haemophilus type b, pneumococcal conjugate, meningococcal (conjugate and polysacchaKeeping and Immunization Information Systems, p 40]). In addition to adverse events, vaccine product problems and vaccine administration errors may be reported. Vaccine purchased with: Private funds Military funds Other/unknown Public funds 17. Previous doses Date given Manufacturer Lot number Route/Site Military clinic/hospital Other/unknown 19. A precaution also may exist for conditions that might compromise the ability of the vaccine to produce immunity (eg, administering measles vaccine to a person with passive immunity to measles from a blood transfusion). Failure to understand true contraindications and precautions can result in administration of a vaccine when it should be withheld (see Immunization in Immunocompromised Children, p 74). Everyone should be screened before every vaccine dose, even if screened during a prior visit. The only contraindication applicable to all vaccines is a history of a severe allergic reaction (ie, anaphylaxis) after a previous dose of that vaccine or a component of that vaccine. Pregnant women should not receive live-virus vaccines because of a theoretical risk to the fetus. The presence of a moderate or severe acute illness with or without a fever is a precaution to administration of all vaccines. The decision to administer or delay vaccination because of a current or recent acute illness depends on the severity of symptoms and etiology of the condition. Delaying avoids causing diagnostic confusion between manifestations of the underlying illness and possible adverse effects of vaccination or superimposing adverse effects of the vaccine on the underlying illness. Vaccination should not be delayed because of the presence of mild respiratory tract illness or other acute mild illnesses with or without fever. The safety and immunogenicity of vaccinating people with mild illnesses have been documented. Routine physical examiing people who appear to be healthy, but the provider should ask the parent or guardian whether the child is ill. Clinicians might misperceive certain conditions or circumstances as valid contraindications or precautions to vaccination when they do not preclude vaccination. Even when the child truly is allergic and no alternative vaccines are available, in almost all cases, the risk of remaining unimmunized exceeds the risk of careprepared to recognize and treat anaphylaxis, should it occur. The proteins most often implicated in vaccine reactions are ovalbumin or other egg white proteins and gelatin, with perhaps rare reactions to yeast or latex. Most immediate hypersensitivity reactions after measles or mumps immunization appear to be reactions to other vaccine components, such as gelatin. The vaccine package insert describes a protocol involving skin testing the patient with the vaccine and if positive, giving the vaccine in graded doses. People with a history of food allergy to gelatin may develop anaphylaxis after receipt of gelatin-containing vaccines. In theory, vaccine recipients with hypersensitivity to yeast could experience an allergic reaction to these vaccines. Allergy to yeast is rare; however, patients claiming such an allergy should allergy and to administer the vaccine under observation and in accordance with established protocols. Other vaccine vials and syringes contain synthetic rubber that poses no risk to the latex-allergic child.
These patients may have musculoskeletal problems including scoliosis muscle relaxant gaba generic nimotop 30 mg line, pectus deformities spasms near ribs nimotop 30mg with mastercard, hip dysplasia spasms left side under rib cage generic nimotop 30 mg fast delivery, and flatfeet spasms from acid reflux generic 30mg nimotop overnight delivery. Treatment, however, must be tailored to each individual patient as these syndromes often affect multiple body systems and require involvement of multiple medical disciplines. Health Care Utilization: Syndromes, Children & Adolescents Syndromes with musculoskeletal implications were diagnosed in 328,600 children and adolescent health care visits in 2012, of which 126,300 had a primary diagnosis of a syndrome condition. About 1 in 10 (9%) children and adolescents with any syndrome with musculoskeletal implications diagnoses were hospitalized (29,800), but less than 1% (600) with a primary diagnosis of a syndrome with musculoskeletal implications had a hospital discharge. Infants and young children under the age of 5 years had the highest rate of hospitalization for any diagnoses of syndromes with musculoskeletal implications. The number of hospitalizations with a primary diagnosis was too small for analysis by sex and age. Any diagnoses of syndromes with musculoskeletal implications accounted for 6% of hospitalizations for any musculoskeletal condition diagnosis, and 0. Total hospital charges for primary syndrome with musculoskeletal implications discharges in 2012 were $60. As a result, there has been a commensurate increase in pediatric sportsrelated injuries, both acute and related to chronic overuse. Coordination and mechanics are less developed in pediatric athletes, placing them at greater risk for injuries related to falls and collisions. Growing athletes are at risk for most of the same injuries as adult athletes, but are uniquely susceptible to injuries about the physes and growth cartilage. Not only do these physeal (growth plate) and apophyseal injuries4 require unique treatments, but they may also result in growth derangement that can have long-term consequences. Adolescent female athletes also have been shown to have a two- to nine-fold greater risk of knee injuries, which may be related to age and gender-specific differences in anatomy, neuromuscular control, and hormone levels. Caine D, Caine C, Maffulli N: Incidence and distribution of pediatric sport-related injuries. Apophyseal injuries, unique in the adolescent athlete, cause inflammation at the site of a major tendinous insertion onto a growing bony prominence. Prevalence: Sports Injuries, Children & Adolescents On average across the years from 2011 to 2013, 1. Data reported is from consumer productrelated injuries occurring in the United States from a statistically valid sample of emergency departments collected by the United States Consumer Product Safety Commission, National Electronic Injury Surveillance System. Males report injuries at twice the number as females, with the highest number of injuries occurring in the junior high (11 to 13 years) and high school (14 to 17 years) ages. Basketball had the highest number of team sport related injuries at 33%, and was closely followed by football at 32%. Nearly half (45%) of team sport injuries to children and adolescents occurred during the high school years (age 14 to 17 years), with another 28% in the junior-high age range of 11 to 13 years. Volleyball had the highest proportion of sprains and strains, followed by basketball. Baseball led in contusion injuries, while fractures occurred most frequently in football, hockey (including field, ice, and roller hockey), and soccer. Individual Sports Injuries: Sports Injuries, Children & Adolescents Individual sports injuries accounted for 53% of total injuries reported (970,500). One in five injuries occurred while riding bicycles or other nonmotorized wheeled equipment such as tricycles and scooters. These injuries occurred most frequently to children ages 6 to 10 years, but were common at all ages. Injuries on playground equipment were the second highest type of individual sport injuries, accounting for 15% of all injuries. Playground equipment injuries occurred almost exclusively to children age 10 years or younger. Skating injuries, which includes roller and ice skates, inline skates, and skateboards, were the cause of 11% of individual sport injuries. Females accounted for a larger share of individual sport injuries (43%) than in team sports. Still, the only activity in which females had a significantly higher number of injuries than males was in gymnastics/cheerleading/dancing. However, the type of musculoskeletal injury varied substantially with the type of activity. Fractures resulted from playground equipment injuries onehalf the time, and there were a higher share of fractures in snow sports and skating injuries as well. Sprains/strains occurred in two-thirds of track and field injuries, and there were a higher share of sprains/strains occurring in gymnastics/cheerleading/dancing and fitness training injury category as well. The most common type of injury reported from bicycle/wheeled equipment were contusions. Watkins-Castillo, PhD Skeletal dysplasias, also referred to as osteochondrodysplasias, are a heterogeneous group of disorders that affect the growth and development of bone and cartilage. There is great variability of severity and involvement ranging from neonatal lethality to mild growth differences noted incidentally in adulthood. Hundreds of such dysplasias have been described but most are so rare that true incidence is difficult to estimate. The overall incidence of skeletal dysplasias is two to five per 10,000 live births. Because of the rarity of skeletal dysplasias, data on health care visits for these conditions is too small to be reported. They can be categorized as either benign or malignant, as has been done for this document. Musculoskeletal neoplasms are often also categorized by the type of tissue they produce or from which they are derived. Most benign tumors, such as nonossifying fibromas, result in little or no disability and require no treatment. Simple bone cysts can weaken the bone and increase fracture risk, and may require surgery treatment in order to resolve the cyst and prevent fracture. Other benign tumors include lipomas, fibrous dysplasia, enchondromas, osteoid osteoma, and osteoblastomas. The most common malignant tumors of the pediatric musculoskeletal system are osteosarcoma, Ewing sarcoma/peripheral neuroectodermal tumor, rhabdomyosarcoma, and synovial cell sarcoma. Osteosarcoma is the most common malignant bone tumor in patients under 20 years of age, with an incidence of around 29 per 1 million people. Ewing sarcoma is the second most common pediatric malignant musculoskeletal tumor and is part of the Ewing family of tumors, which includes peripheral neuroectodermal tumors. For additional information on musculoskeletal tumors in children you can refer to the Tumors section of this report. Genetic translocation is the process of exchange of genetic material between chromosomes. A balanced translocation results in no gain or loss of material, while an unbalanced translocation may result in trisomy or monosomy of a particular chromosome segment. A trisomy is a type of polysomy in which there are three instances of a particular chromosome, instead of the normal two-one from each parent. Health Care Utilization: Neoplasms, Children & Adolescents Neoplasms, including both benign and malignant, were diagnosed in 140,700 children and adolescent health care visits in 2012, of which 84,500 had a primary diagnosis of a neoplasm. About one in five (18%) of children and adolescents with any neoplasm diagnoses were hospitalized (25,600), but fewer than 5% (4,000) with a primary diagnosis of a neoplasm had a hospital discharge. As children age, there is a higher incidence of neoplasm prevalence resulting in hospitalization. Any diagnoses of neoplasm accounted for 5% of hospitalizations for any musculoskeletal condition diagnosis, and 0. Mean charges and length of stay were highest for children ages 14 to 17 years, but the increase rose steadily from the youngest patients. Total hospital charges for primary neoplasm diagnosis discharges in 2012 were $336. Watkins-Castillo, PhD An estimated 300,000 children in the Unites States are diagnosed with juvenile arthritis or another chronic rheumatologic condition such as systemic lupus erythematosus, juvenile dermatomyositis, or linear scleroderma. There are seven distinct subtypes, each having a different presentation and association to autoimmunity and genetics. Systemic scleroderma, also called diffuse cutaneous systemic scleroderma, is rare in childhood, accounting for only 2% to 3% of all cases of this condition, which has an estimated prevalence of 24 cases per 100,000 people.
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The essential feature of spinal referred pain that 14 distinguishes it from neurogenic and radicular pain (see below) is that it is nociceptive in nature: the pain is initiated by stimulation of nerve endings of afferent fibers that innervate the vertebral column and its adnexa muscle relaxant lodine best nimotop 30mg. Afferent fibers from the region of referred pain are not stimulated by the causative lesion muscle relaxant mechanism order 30mg nimotop free shipping. Ectopic activation may occur as a result of mechanical deformation of a dorsal root ganglion muscle relaxant pharmacology purchase nimotop 30mg without prescription, mechanical stimulation of previously damaged nerve roots spasms 1983 trailer generic nimotop 30 mg without prescription, inflammation of a dorsal root ganglion, and possibly by ischemic damage to dorsal root ganglia (Howe et al. Ectopic activation results in pain being perceived as arising in the territory supplied by the affected axons. The disease processes that cause radicular pain are indiscriminate and inescapably also affect nonnociceptive afferents (Howe et al. The latter is felt deeply and is aching in quality; although its central region is recognizable and constant, its margins are hard to define (Kellgren 1938, 1939; Feinstein et al. In contrast, radicular pain is usually lancinating in quality and may be perceived along narrow bands reminiscent of but not identical to the bands of dermatomes (Norlen 1944; Smyth and Wright 1959; McCulloch and Waddell 1980). While also perceived deeply, radicular pain nevertheless has a cutaneous quality in proportion to the number of cutaneous afferent fibers being ectopically activated, i. It stems from an era when the mechanisms of referred pain and radicular pain were poorly understood. It was used to describe pain that appeared to travel along the course of the sciatic nerve. The unfortunate legacy of this term is that it has been applied erroneously to any or all pain of spinal origin perceived in the lower limb. Furthermore, because nerve root compression has been believed to be the cause of sciatica, many forms of referred pain in the lower limb have been erroneously ascribed to this cause. Clinical experiments have shown that the only type of pain that is evoked by stimulating nerve roots is radicular pain as described above (Norlen 1944; Smyth and Wright 1959; McCulloch and Waddell 1980). Consequently, at the most, sciatica and radicular pain can be considered as synonymous. However, there is no justification on physiological grounds for equating sciatica and referred pain. Pain in the lower limb should be described specifically as either referred pain or radicular pain. In cases of doubt no implication should be made and the pain should be described as pain in the lower limb. This is because pain in the back tends not to discriminate much among the different diagnostic groups. Chronic back pain without a radicular component is generally aching, dull, or burning or any combination of these three features. Radicular pain is often stabbing or shooting with paresthesias, and tingling or lancinating elements, but may well occur against a background of more dull aching pain. Conditions that are associated with spinal pain whose cause can reasonably be attributed to a demonstrable lesion or otherwise recognizable diathesis; 2. Conditions that may be recognized clinically and for which there is no dispute about their definition but for which a specific diagnosis in anatomic or pathologic terms is either not available or is not justifiable; and 3. Conditions that in some circles are considered controversial or unproven, but which in other circles are staunchly endorsed. Conditions in which the spinal pain can reasonably be attributed to a demonstrable lesion would be more appropriately coded in terms of the primary diagnosis. There is no special need to elaborate a diagnosis and classification system based on the pain they cause when these conditions are otherwise already classifiable. For example, tumors may cause spinal pain, but once the diagnosis is established, the condition should be classified as "tumor," followed by the pathologic nature of the tumor and the region of the spine that it affects. For conditions that are considered still controversial or unproven, the Committee has formulated criteria that should be fully satisfied before the diagnosis is ascribed. The Committee also accepts the use of such diagnoses on a presumptive basis without the criteria being satisfied. In adopting this stance, the Committee seeks to mediate contemporary controversies by on the one hand acknowledging novel or controversial entities while on the other hand outlining criteria that if satisfied should assuage skepticism about the validity of the diagnosis. In this regard, the Committee hopes to facilitate the evolution of knowledge in this field by outlining contemporary standards of scientific thought. In this way, the following taxonomy is designed not to be limiting or prescriptive but to provide options reflecting the diversity of current approaches and attitudes to the problem of spinal pain. The next section below incorporates definitions of radicular pain and radiculopathy. Technically, radicular pain is not a spinal pain, for it is not perceived in any region of the vertebral column; it is perceived in the limbs or around a segment of the body wall. However, it is mentioned in the context of spinal pain for not uncommonly radicular pain is associated with spinal pain, and in some instances but not always, both forms Principles the symptom of spinal pain should be described in terms of its location and nature using the definitions supplied on pages 11 and 12; these descriptions, however, do not establish a diagnosis. As far as possible, the actual diagnosis of spinal pain should be expressed simultaneously along two axes: an anatomic axis specifying the structure that is the source of pain, including its regional or segmental location, and a pathologic axis specifying the pathological basis for the cause of pain, e. In some cases both forms of pain may stem from the one lesion and a single diagnosis can be formulated, e. It is, however, illegitimate to diagnose or classify any form of spinal pain as radicular pain or in terms relating to radicular pain. Radicular pain in isolation is strictly a pain problem of the affected limb or body wall segment. When associated with spinal pain, the spinal pain warrants an independent classification to which the classification of the radicular pain may then be appended. Similarly, radiculopathy may occur in conjunction with spinal pain, but radiculopathy involves loss of conduction in sensory or motor axons, or both, in a nerve root, and there is no evidence that such conduction loss can be a cause of spinal pain. Consequently, it is illegitimate to classify spinal pain in terms of any radiculopathy that may be associated with it. As with radicular pain, the spinal pain should be classified independently, supplemented if required by a classification of the radiculopathy. In classifying spinal pain, it is immaterial whether or not the spinal pain is associated with referred pain; the extent or distribution of referred pain has no bearing on the underlying cause of the spinal pain. Both the spinal pain and the referred pain are caused by the same lesion (unless one believes the patient is suffering from two independent pain problems), and identifying the location or extent of any referred pain has little bearing on formulating a diagnosis. Consequently, in this taxonomy spinal pain problems are classified according to their location but without deference to the presence or distribution of any referred pain. In compiling a taxonomy based on anatomical and pathological axes, the Committee has endeavored to provide a workable system of diagnostic criteria which may help to order the primary phenomena. The complete assessment of a patient requires attention beyond the anatomical diagnosis to consider the psychological, social, and vocational context and consequences of pain and their significance. Foraminal stenosis due to vertical subluxation of the intervertebral joint, osteophytes stemming from the zygapophysial joint or intervertebral disk, buckling of the ligamentum flavum, or a combination of any of the above. Prolapsed intervertebral disk material that elicits an inflammatory reaction in the vertebral canal that secondarily produces inflammation of adjacent neural elements. Radiculitis caused by inflammatory exudates leaking from an intervertebral disk in the absence of frank prolapse. Radiculitis caused by viral infection or postviral inflammation of a dorsal root ganglion, e. Diagnosis: the diagnosis can be ascribed on clinical grounds alone if the appropriate clinical features are present. Where possible the segmental level of the affected spinal nerve should be specified. The affected nerve but not the causative lesion can be specified if in the presence of the appropriate clinical features, a selective spinal nerve block abolishes the pain. There is no evidence that the mechanism underlying radicular pain can cause spinal pain alone. Radicular pain may occur alone, in the absence of spinal pain, whereupon it should be classified as limb pain or trunk pain according to its perceived distribution. When present in conjunction with spinal pain, the two should in the first instance be defined and diagnosed separately, for there is no prima facie reason to maintain that both pains will have exactly the same cause. Clinical Features: the pain is lancinating in quality and travels along a narrow band. It may be episodic, recurrent, or paroxysmal according to the causative lesion or any superimposed aggravating factors. Clinical Features: Subjective sensations of numbness and weakness, confirmed objectively by neurological examination and/or by electrodiagnostic means, occurring in the distribution of a spinal nerve. Radiculopathy may occur in isolation or in association with radicular pain, referred pain, or spinal pain. Paresthesias in a dermatomal distribution can be caused by ischemia of a spinal nerve or its roots, and may be regarded as a feature of incipient conduction block and therefore a feature of radiculopathy.
Multifaceted approaches that include numerous elements of one or more of the above strategies muscle relaxant 563 pliva cheap 30 mg nimotop mastercard. Standard care without a strategy for improving appropriate use of antibiotics: We use the terms usual care and standard care synonymously spasms everywhere cheap 30 mg nimotop with amex. Although practice probably varies considerably between settings spasms and spasticity purchase nimotop 30mg visa, usual and standard practice likely includes maintaining hydration and use of decongestants muscle relaxant alcoholism cheap 30 mg nimotop free shipping, cough suppressant, etc. Full-text of all citations deemed potentially eligible for inclusion by at least one reviewer were obtained for further evaluation. Full-text articles were reviewed by two reviewers, with differences in judgment on eligibility resolved through consensus or inclusion of a third party. Results published only in abstract form were not included because inadequate details were available for assessing quality. In general, at full-text level, studies were excluded for one or more of the following reasons: ineligible population, ineligible intervention, ineligible comparator, ineligible outcome, ineligible setting (e. All citations were entered in an electronic database (Endnote X7, Thomson Reuters) and screening decisions for each citation were also tracked in the database. Appendix B lists all studies included at full text, while all studies excluded at full text are listed in Appendix C. Data Extraction the following data were abstracted from included studies: study design, number of participants randomized or enrolled, patient and provider population criteria, intervention strategy and comparator characteristics, patient characteristics (e. One reviewer abstracted study data, and a second reviewer appraised the abstractions. Preventive Services Task Force and the National Health Service Centre for Reviews and Dissemination (United Kingdom). The internal validity of observational studies were rated based on criteria specific to these study designs: the adequacy of the patient selection process, whether there was important differential loss to followup or overall high loss to followup, the adequacy of event ascertainment, whether acceptable statistical techniques were used to minimize potential 12 confounding factors, and whether the duration of followup was reasonable to capture investigated events. All assessments were done at the overall study level and resulted in a rating of good, fair, or poor. We utilized a dual rating procedure for study quality, where all studies were first rated by one reviewer and then checked by another reviewer. Data Synthesis Evidence tables were constructed to illustrate the study characteristics, quality ratings, and results for all included studies (Appendixes D through I). A hierarchy-of-evidence approach was used, where the best evidence is the focus of our synthesis for each question, population, intervention, and outcome addressed. High-quality systematic reviews that had a similar scope to our review were used as primary evidence where possible; where a review included all studies of an intervention, population, and outcome we summarized the findings of the review as our evidence. Where an eligible review did not include all identified studies we noted the review and its findings, but undertook a new synthesis to incorporate the newer studies not included in the review. For assessing overall and appropriate prescribing and use, we accepted and recorded all definition and measurement methods. Particularly for appropriate prescribing outcomes, we grouped together studies that use similar definitions of appropriateness and evaluated whether the comparative effectiveness of strategies differed across categories. Where appropriate, we synthesized outcome data quantitatively using meta-analysis to pool outcomes, with odds ratio as the principle summary measure. Data from poor-quality studies were generally excluded from the synthesis, except to undertake sensitivity analyses or to note where high risk of bias studies constitute the only evidence for an important outcome. To determine the appropriateness of meta-analysis, we considered the internal validity of the studies and the heterogeneity among studies in design, patient population, interventions, and outcomes. The Q statistic and the I2 statistic (the proportion of variation in study estimates due to heterogeneity) were calculated to assess heterogeneity in effects between studies. Forest plots were used when applicable to graphically summarize the results of individual studies and of the pooled analysis. Since most data was not suitable for pooling, we largely summarized the data qualitatively. Qualitative synthesis involved grouping studies by similarity of population and/or intervention characteristics, including the sources of variation or heterogeneity listed above. When definition of appropriate antibiotic use and/or prescription were provided, we grouped together studies that used similar definitions of appropriateness and categorized the different groups based on concordance (e. We then evaluated whether the comparative effectiveness of strategies differed across categories. As described in Key Question 1, we looked for studies with outcomes on appropriate antibiotic prescribing and use. However, most studies did not measure outcomes in this way and the few studies that attempted to assess appropriate prescribing had important limitations in outcome definition and ascertainment methods and lack of consistency in methods across studies. Similarly, very few studies measured actual use of prescribed antibiotics and even fewer studies reported antibiotic resistance as an outcome. Although no study examined all possible adverse consequences, we considered evidence suggesting no adverse consequences (equal or lower hospitalization, equal or lower return visits, equal or higher patient/parent satisfaction) as reassuring. To present the evidence in the most useful format for decisionmakers, we grouped the interventions into four categories based on the direction and strength of evidence for benefits (prescribing and/or resistance) and adverse consequences (e. Within this group, interventions with the highest combined level of evidence (benefits and harms) were emphasized. In either case, this group represents interventions that require further study to make a determination on their overall effect. The two situations (a and b) are discussed separately as the implications for future research differ. Given the large number of interventions to consider, those with insufficient evidence are not discussed in detail in the Executive Summary. The evidence provided limited opportunity to examine potential publication and reporting biases, primarily because there were so few opportunities for meta-analysis and because so few study protocols were available. Domains considered in grading the strength of evidence included study limitations, consistency, directness, precision, and reporting bias. For evaluating precision, we did not assume any minimum important difference for continuous outcomes, as we are not aware of any that have been validated. So, we accepted any delta and assessed optimal information size for each delta separately. Based on assessment of these domains, the body of evidence was assigned a strength-of-evidence grade of high, moderate, or low. In cases where evidence did not exist, was sparse, or contained irreconcilable inconsistency, a grade of insufficient evidence was assigned (see Appendix J). Applicability Applicability was assessed by paying special attention to study eligibility criteria, characteristics of the enrolled population in comparison to the target population, characteristics of the intervention and comparator used in comparison with care models currently in use, and clinical relevance and timing of the outcome measures. Based on these sources, a total of 6,245 abstracts were screened of which 389 articles were retrieved and assessed for eligibility. Of the 143 publications included in this report, 133 were primary study reports22,24-27,41-54,56,58-84,8692,95-133,135-142,144-146,148-157,159-177 and 10 were secondary publications. In terms of outcomes, overall antibiotic prescription was the most widely studied, followed by return visits, symptom improvement and patient satisfaction. Changes in overall prescribing was reported in all studies, while attempts to measure changes in appropriate or inappropriate prescribing were reported in only nine studies (7%). However, actual use of antibiotics was rarely reported; the studies of delayed prescribing report patient self-report of filling the prescription and sometimes use of the prescription. Antibiotic resistance and quality of life were only reported in one study each, and some outcomes (e. The proportion of studies conducted in the United States was 45 percent overall; but this ranged widely across intervention categories, from 14 percent for communication strategies to 69 percent for system-level strategies. Data abstraction tables for all included studies can be found in Appendixes D, F, and H.
References