Where and to what extent is prevention of low birth weight possible?

Law birth weight (LBW), due to shortened gestation and/or inadequate fetal growth. is the major determinant of infant mortality and morbidity. Despite improvements in infant mortality, them has been no reduction in LBW rates. The authors examined the relationship between 33 maternal characteristics and the increased risks of preterm (PT) delivery or small-for-gestational-age (SGA) births in 76,444 Alberta women 1994-1997. PT was associated with preexisting medical conditions, obstetrical history, and pregnancy complications. Modifiable factors such as advanced maternal age contributed only 11% to the overall PT risk. SGA births were associated with several modifiable factors, including low prepregnancy weight, maternal age, smoking, drinking, and drug dependency. These contributed to 29% and 31% of PTand term SGA births. Smoking remains an important target for intervention, having contributed to 8% of PT births and about 24% of SGA births. SGA appears to be more amenable to prevention than PT delivery.     

Nutrition and infection in the intensive care unit: what does the evidence show?

PURPOSE OF REVIEW: Nutrition support when applied appropriately, can improve clinical outcomes, particularly the incidence of infections. The Canadian Clinical Practice Guidelines for Nutrition Support, published in October 2003, summarized the evidence on nutrition support in the critically ill patient and provided recommendations aimed at maximizing the benefits of nutrition support while minimizing the risks. The purpose of this review is to highlight recent advances in nutrition research in critically ill adult patients, particularly with respect to minimizing infection. The newly published data will be used to update the Canadian Clinical Practice Guidelines. RECENT FINDINGS: Recent studies have confirmed that the use of enteral nutrition versus parenteral nutrition, early initiation of enteral nutrition, use of enteral and parenteral glutamine and intensive insulin therapy are all associated with reduced infectious morbidity in critically ill patients. A recent meta-analysis suggests that antioxidant supplementation is associated with no improvement in infectious complications, but an increase in survival. The recommendations from the Canadian Clinical Practice Guidelines for Nutrition Support have been updated based on the data from these recent trials. SUMMARY: This review provides insights into the results of recent randomized trials on nutrition support in critically ill patients. The Canadian Clinical Practice Guidelines for nutrition support help intensive care unit clinicians to keep abreast of emerging evidence and the impact of nutrition support practices on outcomes such as infections.     

Falls and their prevention in elderly people: what does the evidence show?

A large proportion of falls and fall injuries in older people is due to multiple risk factors, many of which probably can be modified or eliminated with targeted fall prevention interventions. These interventions must be feasible, sustainable, and cost effective to be practical for widespread use. The most promising prevention strategies involve multidimensional fall risk assessment and exercise interventions. Incorporating these intervention strategies whenever feasible into a fall prevention program seems to be the most effective means for fall prevention in older adults.     

Biochemical markers for preterm labor and birth: what is their role in the care of pregnant women?

Two biochemical tests, one for oncofetal fibronectin (fFN) and the other for estriol found in maternal saliva (SalEst) have been developed to improve the ability to predict preterm labor and birth. Fetal fibronectin is a protein secreted by the trophoblast and not normally present in vaginal and cervical secretions late in pregnancy. The presence of fFN between 22 and 37 weeks gestation may be a marker for preterm labor. Salivary estriol is a form of estrogen produced in the placenta from fetal precursors. Normally, estriol rises during pregnancy--the rise being accelerated 3 to 5 weeks prior to both term and preterm births. Both tests have high negative predictive values. This may serve to prevent unnecessary treatment of women with uterine contractions who are not truly in preterm labor. The fFN specimen is collected during vaginal examination. Sexual intercourse or vaginal examination within the prior 24 hours, vaginal bleeding, and uterine contractions may lead to a false positive test. Salivary estriol may be collected by the woman in her own home; however, specific instructions about eating, drinking, smoking, and the timing of saliva collection must be followed. Further study of both tests is required to determine their potential for reducing rates of preterm birth.     

Interventions for low back pain: What does the evidence tell us?

Although interventional therapy for chronic spinal pain continues to be popular among patients and providers, the scientific evidence supporting these techniques has lagged behind their presence in the market. This article collates both classic and more recent experimental results involved in the interventional assessment and treatment of chronic spinal pain, and presents key findings for physicians. Although much of the body of evidence is either unsupportive or inconclusive, there are some definitive findings involving each technique that can help shape rational practice. As interventional pain medicine seeks to become a more validated specialty, introspection and advancing science will be key to this development.     

Smoking cessation readiness: are your patients ready to quit?

Purpose: To explore the assessment of patient readiness to receive smoking cessation interventions using the transtheoretical model (TTM) and the five stages of change; and to give the primary care provider an evidence-based toolkit to assist in evaluating for readiness and supporting the smoking cessation process.
Data sources: Evidence-based literature, theoretical framework, and peer-reviewed articles.
Conclusions: Utilizing the TTM along with proper training and education of the provider and patient increases the probability that smoking cessation will occur. Combinations of pharmaceutical and nonpharmaceutical interventions are the most effective in smoking cessation.
Implications for practice: Providers can be prepared at every patient visit to address the smoking cessation needs of all patients. The toolkit provided in this article will help facilitate evaluation of readiness and support of effective, long-term smoking cessation and reduce eventual smoking-related morbidities.     

Methylxanthine use in anaphylaxis: what does the evidence tell us?

OBJECTIVE: To review the literature examining the use of methylxanthines in the treatment of anaphylaxis. DATA SOURCES: A MEDLINE search (January 1966-December 1998) was performed using the terms aminophylline, theophylline, and anaphylaxis. STUDY SELECTION AND DATA EXTRACTION: Articles discussing methylxanthine use in anaphylaxis were independently examined by each author. Additional information was obtained through the references of these articles. Articles not written in English were excluded. DATA SYNTHESIS: No human studies were identified. Limited published data were found in animal models of anaphylaxis. CONCLUSIONS: Safer agents with proven efficacy exist for the treatment of bronchoconstriction in anaphylaxis. Until data are available in humans, methylxanthines should not be recommended in the treatment of anaphylactic reactions.     

Efficacy of Hoodia for weight loss: is there evidence to support the efficacy claims?

Increasing rates of adult obesity and its negative health consequences are likely to become an increasing burden to the Canadian health care system. Consumers are looking for treatment options and often try the natural health products that are heavily promoted as safe, fast and effective. In this case report, MH, a 57‐year‐old overweight female wanted advice regarding whether she should use the natural product Hoodia to help her attain her weight loss goals. A literature search was conducted using Medline, EMBASE, the Cochrane Library, Natural Medicines Comprehensive Database and IPA from inception to March 2009. The internet, files of the authors and bibliographies of articles were searched for additional references. No published, peer‐reviewed randomized controlled trials examining efficacy of Hoodia were found. Unpublished data from two small trials reported promising results with no adverse events. However, this leaves many unanswered questions regarding the use of Hoodia for weight loss such as the appropriate dose and duration, short and long term safety and use in patients with concomitant diseases. Literature suggests that some commercial products may not actually contain Hoodia at all. Additionally, Hoodia is not yet listed in the Canadian Licensed Natural Health Products Database meaning products sold in Canada may not meet Canadian regulatory standards. Upon discussing this information, MH decided not to use Hoodia, and other evidence‐based recommendations were discussed.     

Complementary therapies: what is the evidence for their use?

Complementary therapies are being increasingly used by patients and health-care professionals, but often with little awareness of the evidence for their use. The Internet offers a valuable and easy-to-use resource for assessing a growing amount of published information. Nurses need to be aware of a treatment's effectiveness and warn patients of potential risks or unprofessional claims.     

Combination therapy for Gram-negative bacteria: what is the evidence?

The treatment of infections caused by multidrug-resistant Gram-negative bacteria is challenging given the limited options for effective therapy. Combination therapy has garnered great interest recently, with the goals of ensuring appropriate therapy with at least one active agent, and achieving synergistic activity among the anti-microbials used. In this review, we evaluate the data supporting the use of combination therapy against Pseudomonas aeruginosa, carbapenem-resistant Enterobacteriaceae, Acinetobacter species and Stenotrophomonas maltophilia. Various regimens have been tried with promising results; however, the data are mostly derived from in vitro synergy studies. While these reports suggest an advantage of combination therapy over monotherapy, clinical data are scarce, and are comprised of retrospective and a few prospective observational studies. Well-designed randomized trials are needed to better elucidate the efficacy of the various combination regimens. Until then, this review offers a critical appraisal of the published literature and provides recommendations based on the available evidence.     

Is the evidence for the use of subglottic drainage to prevent ventilated-associated pneumonia sufficient to change practice?

This paper critiques the systematic review and meta-analysis of the effect of subglottic drainage among patients who received mechanical ventilation. Subglottic secretion drainage can reduce bacterial pathogens from entering the lower respiratory tract and potentially reduce the occurrence of ventilator-associated pneumonia. A summary of the systematic review and meta-analysis is provided. The critique examines the study's strengths and weaknesses and implications for practice are discussed. It is a well-conducted systematic review and meta-analysis with few suggestions for improvement. Subglottic secretion drainage reduced the incidence of ventilator-associated pneumonia. Several studies have shown positive effects of using subglottic drainage but despite the evidence, the practice in ICUs is not widespread.     

The transition to parenthood: what does it mean for fathers?

Title. The transition to parenthood: what does it mean for fathers? Aim. This paper is a report of a study to explore the needs of first‐time fathers in relation to the care, support and education provided by healthcare professionals during the antenatal period, particularly in relation to preparing them for the transition to fatherhood. Background. Pregnancy and transition to parenthood are major developmental periods within families throughout the world. Previous research suggests that fathers in many different countries feel unprepared for parenthood. Methods. Purposive sampling was used to recruit 20 partners of primiparous women from two healthcare provider organizations in South‐West England between December 2005 and July 2006. Recruitment took place at about 28 weeks gestation. Semi‐structured interviews were undertaken at home in the last trimester of pregnancy and 3–4 months postpartum. Content analysis of the interview data was undertaken. Findings. Several common themes emerged from both the ante‐ and postnatal data, including lack of support mechanisms, involvement in antenatal provision and the need for more information given in the antenatal period on parenting, baby care and relationships. Conclusions. Adequately preparing new fathers for parenthood in advance of the birth of their baby is important, and healthcare professionals can contribute to this by involving and supporting new fathers. Further study is needed to explore the role of fathers in antenatal education and the types of interventions that are effective in improving their early experiences of parenthood. The study needs to be repeated with fathers from black and ethnic minority groups.     

Cholesterol reduction to prevent CAD. What do the data show?

Primary prevention of heart disease should be an important goal of every primary care physician. All patients should undergo careful assessment of future risk and should be counseled about lifestyle modification. Patients at high risk can further benefit from cautious use of lipid-lowering drugs, which have been shown to be effective in preventing cardiac events without substantially increasing risk of noncardiac morbidity and mortality.