Vitamin D: A Narrative Review Examining the Evidence for Ten Beliefs

Over the past decade, a large body of observational evidence has suggested an association between lower vitamin D status (25-hydroxyvitamin D) and multiple acute and chronic disorders, including cancer, multiple sclerosis, depression and respiratory tract infections. This evidence has fostered the hypothesis that increasing vitamin D intake may treat and prevent such disorders. Our objective was to perform a critical analysis of the highest-level evidence for ten common beliefs regarding vitamin D for the prevention of falls, fractures and respiratory tract infections, the reduction of cancer incidence/mortality and overall mortality, and the prevention or treatment of depression/mental well-being, rheumatoid arthritis and multiple sclerosis, as well as maximum dosing and regular testing. We searched the Cochrane Database of Systematic Reviews and PubMed (up to August 2014) for randomized controlled trials and systematic reviews/meta-analyses based on those studies. All searches were performed, all evidence reviewed and each section written by at least two authors. The evidence shows that vitamin D supplementation provides some benefit in fracture prevention (likely ～10–15 % relative reduction), particularly at a dose ≥800 IU and with calcium; a likely benefit in the rate of falls, though it is less clear whether the number of fallers changes; and a possible small (～5 %) relative reduction in mortality. Evidence does not support the use of vitamin D supplementation for the prevention of cancer, respiratory infections or rheumatoid arthritis. Similarly, evidence does not support vitamin D supplementation for the treatment of multiple sclerosis and rheumatoid arthritis or for improving depression/mental well-being. Regular testing of 25-hydroxyvitamin D is generally not required, and mega-doses (≥300,000 IU) appear to increase harms. Much of the evidence is at high risk of bias, with multiple flaws, including analyses of secondary endpoints, small and underpowered studies, inconsistent results and numerous other issues. Therefore, enthusiasm for a vitamin D panacea should be tempered.     

Underuse of Behavioral Treatments for Headache: a Narrative Review Examining Societal and Cultural Factors

Migraine affects over 40 million Americans and is the world’s second most disabling condition. As the majority of medical care for migraine occurs in primary care settings, not in neurology nor headache subspecialty practices, healthcare system interventions should focus on primary care. Though there is grade A evidence for behavioral treatment (e.g., biofeedback, cognitive behavioral therapy (CBT), and relaxation techniques) for migraine, these treatments are underutilized. Behavioral treatments may be a valuable alternative to opioids, which remain widely used for migraine, despite the US opioid epidemic and guidelines that recommend against them. Identifying and removing barriers to the use of headache behavioral therapy could help reduce the disability as well as the personal and social costs of migraine. These techniques will have their greatest impact if offered in primary care settings to the lower socioeconomic status groups at greatest risk for migraine. We review the societal and cultural challenges that impose barriers to optimal use of non-pharmacological treatment services. These barriers include insufficient knowledge of migraine/headache behavioral treatments and insufficient availability of clinicians trained in non-pharmacological treatment delivery; limited access in underserved communities; financial burden; and stigma associated with both headache and mental health diagnoses and treatment. For each barrier, we discuss potential approaches to minimizing its effect and thus enhancing non-pharmacological treatment utilization.Case ExampleA 25-year-old graduate student with a prior history of headaches in college is attending school in the evenings while working a full-time job. Now, his headaches have significant nausea and photophobia. They are twice weekly and are disabling enough that he is unable to complete homework assignments. He does not understand why the headaches occur on Saturdays when he pushes through all week to get through his examinations that take place on Friday evenings. He tried two different migraine preventive medications, but neither led to the 50% reduction in headache days his doctor had hoped for. His doctor had suggested cognitive behavioral therapy (CBT) before initiating the medications, but he had been too busy to attend the appointments, and the challenges in finding an in-network provider proved difficult. Now with the worsening headaches, he opted for the CBT and by the fifth week had already noted improvements in his headache frequency and intensity.KEY WORDS: headache, behavioral interventions, migraine, barriers to care     

Examining the Evidence: A Systematic Review of the Inclusion and Analysis of Older Adults in Randomized Controlled Trials

BACKGROUND  

Due to a shortage of studies focusing on older adults, clinicians and policy makers frequently rely on clinical trials of the general population to provide supportive evidence for treating complex, older patients.     

Against Medical Advice Discharge: A Narrative Review and Recommendations for a Systematic Approach

Approximately 1%-2% of hospitalizations in the United States result in an against medical advice discharge. Still, the practice of discharging patients against medical advice is highly subjective and variable. Discharges against medical advice are associated with physician distress, patient stigma, and adverse outcomes, including increased morbidity and mortality. This review summarizes discharge against medical advice research, proposes a definition for against medical advice discharge, and recommends a standard approach to a patient's request for discharge against medical advice.     

Carotid Revascularization: A Systematic Review of the Evidence

Objective and Background

The aim of this study is to provide an evidence‐based review of the periprocedural safety and long‐term effectiveness of carotid artery stenting (CAS) compared to carotid endarterectomy (CEA), with particular attention paid to the use of embolic protection devices and patients at high risk for CEA.

Methods

Electronic databases (Ovid Medline, Cochrane central register of controlled trials, Pubmed, and Embase) were searched to identify: (1) randomized controlled trials (RCT) comparing outcomes of CEA and CAS, and (2) prospective clinical trials assessing the safety of CAS in patients at high surgical risk. Pooled incidence rates and one‐sided 95% confidence interval for the periprocedural and long‐term composite end‐point of stroke, myocardial infarction, or death among high surgical risk patients were generated and compared to objective performance criteria (OPC) reported by previous trials.

Results

Six RCTs and 14 prospective clinical trials met our search criteria. Selected RCTs showed inconsistency in reported periprocedural and long‐term outcome rates. Pooled incidence rates of the periprocedural and long‐term composite end‐point of stroke, myocardial infarction or death in high surgical risk candidates were 5.59% and 7.92%, respectively. These results were noninferior to selected OPCs (P‐value <0.001).

Conclusions

CAS represents a safe and effective stroke prevention strategy in high surgical risk patients when compared with CEA. The inconsistent results from the RCTs and the improved outcomes in the prospective clinical trials are likely related to variability in operator experience, use of embolic protection devices, and patient selection strategies.

     

Levels of Evidence in Endoscopic Ultrasonography: A Systematic Review

Background and Aims  

A prolific trend currently designates endoscopic ultrasonography (EUS) literature. We aimed to record all EUS-studies published during the past decade and evaluate them in terms of scientific quality, creating a stratification based on levels of evidence (LE).     

Bariatric Surgery: A Systematic Review of the Clinical and Economic Evidence

CONTEXT  

Use of bariatric surgery for severe obesity has increased dramatically.     

Evidence for Distinctive Personality Traits in Alcoholics

A picture-preference test designed to measure ten traits believed to characterize alcoholics was administered to 106 alcoholics, 15 neurotics, and 80 normals. As predicted, alcoholics had higher scores on this test than normals or neurotics. The mean score of the neurotics was virtually the same as the mean of the normals. Whatever is measured by this test reliably distinguishes alcoholics from both neurotics and normals.     

Immune-Mediated Association Between Celiac Disease and Sensorineural Hearing Loss: A Systematic Narrative Review

The auto-immune correlation between sensorineural hearing loss and celiac disease has previously been hypothesized. This review describes available evidence and offers insights for future perspectives. We searched the PubMed database. Studies in the review included children and adults with celiac disease evaluated for hearing loss. Individual case reports and review articles were excluded. The various searches turned in 32 results, of which 10 met the inclusion criteria. Auto-immune hearing loss has been proposed as extra-intestinal symptoms of celiac disease, despite the pathogenetic mechanisms being not entirely clear. Several studies postulated that subclinical hearing loss may be present in children with celiac disease. Despite existing literature not clarifying the link between celiac disease and sensorineural hearing loss, some authors proposed hearing screening in younger patients with celiac disease, to prevent the behavioral, cognitive, and sensorimotor impairment of hearing loss. Further rigorous studies are strongly recommended to better explore the relationship between hearing loss and celiac disease.     

Prediction of Mortality in Acute Pancreatitis: A Systematic Review of the Published Evidence

Objective: In this review, we focus on studies that examined such prognostic indices in relation to predicting a fatal outcome from pancreatitis. Summary Background Data: Acute pancreatitis (AP) is a common emergency, and early identification of high-risk patients can be difficult. For this reason, a plethora of different prognostic variables and scoring systems have been assessed to see if they can reliably predict the severity of pancreatitis and/or subsequent mortality. Methods: All studies that focused on AP, including retrospective series and prospective trials, were retrieved and analysed for factors that could influence mortality. Articles that analysed factors influencing the severity of the disease or the manifestation of disease-related complications were excluded. Results: 58 articles meeting the inclusion criteria were identified. Among the various factors investigated, APACHE II seemed to have the highest positive predictive value (69%). However, most prognostic variables and scores showed high negative predictive values but suboptimal values for positive predictive power. Conclusions: Despite the proliferation of scoring systems for grading AP, none are ideal for the prediction of mortality. With the exception of the APACHE II, the other scores and indexes do not have a high degree of sensitivity, specificity and predictive values.     

Faculty Development for Community Preceptors: a Narrative Review of the Literature

Community teaching physicians (i.e., community preceptors) have assumed an important role in medical education. More than half of medical schools use community settings to train medical students. Whether community preceptors are well prepared for their teaching responsibilities is unknown. In addition, best practice for faculty development (FD) of this population of preceptors has not been defined. The authors conducted a narrative review of the literature to describe FD programs for community preceptors that may be helpful to medical schools for future planning. Many databases were searched from their establishment to May 2022. Studies that described FD programs for community preceptors were included. Data were organized according to program aim, duration, setting, participants, content, and outcomes. The Communities of Practice theoretical framework was used to present findings. From a total of 6308 articles, 326 were eligible for full review, 21 met inclusion criteria. Sixty-seven percent (14/21) conducted a needs assessment; 57% (12/21) were developed by the medical school; 81% (17/21) included only community preceptors. Number of participants ranged from six to 1728. Workshops were often (24%, 5/21) used and supplemented by role-play, online modules, or instructional videos. Few programs offered opportunities to practice with standardized learners. Content focused primarily on teaching skills. Five programs offered CME credits as an incentive for engagement. Participant surveys were most often used for program evaluation. Learner evaluations and focus groups were used less often. Participants reported satisfaction and improvement in teaching skills after attending the program. Faculty development for community preceptors is primarily delivered through workshops and online materials, although direct observations of teaching with feedback from FD faculty and learners may be more helpful for training. Future studies need to focus on the long-term impact of FD on community preceptors’ teaching skills, identity formation as medical educators, and student learning.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-023-08026-5.

Community teaching physicians have assumed an important role in medical education. More than half of medical schools use regional campuses and community settings to train their medical students.¹ The need for training future physicians to better meet societal needs and expectations has prompted medical schools to shift student learning to community settings.^{2, 3} At these sites that are often rural or urban, medical students learn from community practicing physicians (i.e., community preceptors) and better understand how social determinants of health can impact patients and communities.^{4, 5} These experiences can be powerful and may have a lasting effect on medical students’ professional identity formation and career choices.⁶The value of community preceptors in medical education has been increasingly recognized by many organizations.^{7, 8} Community-based medical schools, in particular, depend on these physicians to fulfill their educational mission and provide clinical training to their students.⁹ The Alliance of Academic Internal Medicine has called attention to the important roles of community preceptors and need for faculty development (FD) programs that align with their needs and are mindful of their time constraints and geographic location.¹⁰ Furthermore, medical school accreditation standards require comparability of student learning experiences across training sites demanding teaching physicians who are well prepared for their educator roles.¹¹However, whether community preceptors are well prepared for their teaching responsibilities is unknown. In addition, best practice for FD of this population of preceptors has not been defined.¹² Many organizations have expressed concerns about the shortage of community preceptors and their level of preparedness to provide high-quality educational experiences.^{7, 8, 13, 14} According to a national survey of Family Medicine clerkship directors, FD programs for community preceptors are unstructured or absent, and best practices are lacking.¹³ Community preceptors are often uncertain about their teaching skills and find teaching to be stressful and difficult.¹⁵ Time constraints, high productivity demands, disinterested learners, and lack of training as educators are additional barriers to teaching.¹⁴Given the increasingly important role of community physicians in the educational mission of medical schools, it becomes important to better understand what FD resources are available to them and the scope and outcomes of these FD resources. The literature in this area is less explored since previous studies have primarily focused on the FD of academic teaching faculty. To explore this area of medical education, we conducted a narrative review of the literature with the aim to describe FD programs and identify any gaps that maybe helpful to medical schools and FD developers in the preparation of these teaching physicians for their roles as educators. We used the Communities of Practice (CoP) theoretical framework to present our findings.^{16, 17} We found CoP relevant to community preceptors who may aspire to join the community of medical educators and acquire the necessary knowledge and skills to move from “peripheral participation to full membership” (p. 186). Our review will explore the role of FD in this process.¹⁷     

Teamwork Assessment in Internal Medicine: A Systematic Review of Validity Evidence and Outcomes

OBJECTIVE

Valid teamwork assessment is imperative to determine physician competency and optimize patient outcomes. We systematically reviewed published instruments assessing teamwork in undergraduate, graduate, and continuing medical education in general internal medicine and all medical subspecialties.

DATA SOURCES

We searched MEDLINE, MEDLINE In-process, CINAHL and PsycINFO from January 1979 through October 2012, references of included articles, and abstracts from four professional meetings. Two content experts were queried for additional studies.

STUDY ELIGIBILITY

Included studies described quantitative tools measuring teamwork among medical students, residents, fellows, and practicing physicians on single or multi-professional (interprofessional) teams.

STUDY APPRAISAL AND SYNTHESIS METHODS

Instrument validity and study quality were extracted using established frameworks with existing validity evidence. Two authors independently abstracted 30 % of articles and agreement was calculated.

RESULTS

Of 12,922 citations, 178 articles describing 73 unique teamwork assessment tools met inclusion criteria. Interrater agreement was intraclass correlation coefficient 0.73 (95 % CI 0.63–0.81). Studies involved practicing physicians (142, 80 %), residents/fellows (70, 39 %), and medical students (11, 6 %). The majority (152, 85 %) assessed interprofessional teams. Studies were conducted in inpatient (77, 43 %), outpatient (42, 24 %), simulation (37, 21 %), and classroom (13, 7 %) settings. Validity evidence for the 73 tools included content (54, 74 %), internal structure (51, 70 %), relationships to other variables (25, 34 %), and response process (12, 16 %). Attitudes and opinions were the most frequently assessed outcomes. Relationships between teamwork scores and patient outcomes were directly examined for 13 (18 %) of tools. Scores from the Safety Attitudes Questionnaire and Team Climate Inventory have substantial validity evidence and have been associated with improved patient outcomes.

LIMITATIONS

Review is limited to quantitative assessments of teamwork in internal medicine.

CONCLUSIONS

There is strong validity evidence for several published tools assessing teamwork in internal medicine. However, few teamwork assessments have been directly linked to patient outcomes.     

Evidence and Recommendations for Imaging Liver Fat in Children,Based on Systematic Review

Download : Download video (73MB)Video Abstract     

Effectiveness of Sport-Based HIV Prevention Interventions: A Systematic Review of the Evidence

Interest in sport as a tool for behavioral HIV prevention has grown substantially in the past decade. With dozens of organisations now using sport-based HIV prevention (SBHP) approaches and upcoming randomized controlled trials in South Africa and Zimbabwe, there is a pressing need to synthesize previous evaluation findings and identify gaps in existing research. A systematic review on the effectiveness of SBHP interventions was carried out, identifying both published and unpublished studies on SBHP interventions that measured effectiveness quantitatively. Study quality was scored using an adapted Newcastle-Ottawa Scale. Random-effects meta-analyses were carried out across studies for effects on six categories of HIV-related outcomes. The review identified 952 publications, 21 of which met inclusion criteria. No randomised controlled trials on SBHP interventions and no studies assessing biological outcomes were identified. Mean study quality score was 5.1 (SD 3.1) out of 20 points. Overall strong evidence was observed for positive effects on HIV-related knowledge (RR = 1.26, 95 % CI = 1.15–1.37), stigma (RR = 1.13, 95 % CI = 1.02–1.24), self-efficacy (RR = 1.22, 95 % CI = 1.02–1.41), reported communication (RR = 1.24, 95 % CI = 1.06–1.41), and reported recent condom use (RR = 1.29, 95 % CI = 1.00–1.59). Generally, the review found encouraging evidence for some short-term effects but relied predominantly on low-quality studies. More rigorous research on SBHP is needed to objectively assess effectiveness. Randomised controlled trials could play an important role in guiding policies, strategies, and funding related to SBHP.     

Environmental Chemicals and Type 2 Diabetes: An Updated Systematic Review of the Epidemiologic Evidence

The burden of diabetes is increasing globally. Identifying novel preventable risk factors is an urgent need. In 2011, the U.S. National Toxicological Program (NTP) conducted a workshop to evaluate the epidemiologic and experimental evidence on the relationship of environmental chemicals with obesity, diabetes, and metabolic syndrome. Although the evidence was insufficient to establish causality, the NTP workshop review identified an overall positive association between some environmental chemicals and diabetes. In the present systematic review, our objective was to summarize the epidemiological research published since the NTP workshop. We identified a total of 29 articles (7 on arsenic, 3 on cadmium, 2 on mercury, 11 on persistent organic pollutants, 3 on phthalates, and 4 on bisphenol A), including 7 prospective studies. Considering consistency, temporality, strength, dose–response relationship, and biological plausibility (confounding), we concluded that the evidence is suggestive but not sufficient for a relationship between arsenic and persistent organic pollutants and is insufficient for mercury, phthalates, and bisphenol A. For cadmium, the epidemiologic evidence does not seem to suggest an association with diabetes. Important research questions include the need for additional prospective studies and the evaluation of the dose–response relationship, the role of joint exposures, and effect modification with other comorbidities and genetic variants.     

Synthesizing Gender Based HIV Interventions in Sub-Sahara Africa: A Systematic Review of the Evidence

Gender is a critical component of HIV and sexual risk interventions. Examining the range, effectiveness and methodological rigor of studies that include a gender based component can inform current interventions and future directions for intervention research. This review investigated gender informed intervention studies conducted in sub-Saharan Africa that measured an outcome related to HIV. We reviewed 311 articles, 41 of which met our inclusion criteria, resulting in 11 articles that described eight different studies used in the analyses. The findings demonstrated wide variations in the types of interventions from low intensity educational content to multi-component interventions. Study outcomes were categorized into biological outcomes, HIV risk, behavioral, violence and risk reduction. Most interventions showed positive effects, and although research methodologies varied considerably, longer interventions appeared to be more effective. More research, however, is needed to build the evidence base for effectiveness of gender-based programs in reducing HIV infections in sub-Saharan Africa.     

Impact of Transitional Care Services for Chronically Ill Older Patients: A Systematic Evidence Review

Transitions in care from hospital to primary care for older patients with chronic diseases (CD) are complex and lead to increased mortality and service use. In response to these challenges, transitional care (TC) interventions are being widely implemented. They encompass education on self‐management, discharge planning, structured follow‐up and coordination among the different healthcare professionals. We conducted a systematic review to determine the effectiveness of interventions targeting transitions from hospital to the primary care setting for chronically ill older patients.. Randomized controlled trials were identified through Medline, CINHAL, PsycInfo, EMBASE (1995–2015). Two independent reviewers performed the study selection, data extraction and assessment of study quality (Cochrane “Risk of Bias”). Risk differences (RD) and number needed to treat (NNT) or mean differences (MD) were calculated using a random‐effects model. From 10,234 references, 92 studies were included. Compared to usual care, significantly better outcomes were observed: a lower mortality at 3 (RD: ?0.02 [?0.05, 0.00]; NNT: 50), 6, 12 and 18 months post‐discharge, a lower rate of ED visits at 3 months (RD: ?0.08 [?0.15, ?0.01]; NNT: 13), a lower rate of readmissions at 3 (RD: ?0.08 [?0.14, ?0.03]; NNT: 7), 6, 12 and 18 months and a lower mean of readmission days at 3 (MD: ?1.33; [?2.15, ?0.52]), 6, 12 and 18 months. No significant differences were observed in quality of life. In conclusion, TC improves transitions for older patients and should be included in the reorganization of healthcare services.