To estimate the overall reduction in ovarian cancer risk associated with the use of oral contraceptive pills (OCPs) and whether reduction in risk is affected by specifics of OCP use, such as formulation or duration of use.We searched PubMed, Embase, the Cochrane Database of Systematic Reviews, and ClinicalTrials.gov for studies published from January 1990 to June 2012, with primary analysis of studies published since January 2000.We reviewed 6,476 citations. We included English-language controlled studies with human participants reporting a quantitative association between exposure to OCPs (in which the explicit or implicit indication for OCP use was prevention of pregnancy or ovarian cancer) compared with no use of OCPs. Two investigators independently reviewed the title and abstract and full-text of articles for inclusion or exclusion decision; discordant decisions were resolved by team review and consensus.Fifty-five studies met inclusion criteria. A random-effects meta-analysis of 24 case-control and cohort studies showed significant reduction in ovarian cancer incidence in ever-users compared with never-users (odds ratio 0.73, 95% confidence interval 0.66-0.81). There was a significant duration-response relationship, with reduction in incidence of more than 50% among women using OCPs for 10 or more years. The lifetime reduction in ovarian cancer attributable to the use of OCPs is approximately 0.54% for a number-needed-to-treat of approximately 185 for a use period of 5 years.Significant duration-dependent reductions in ovarian cancer incidence in the general population are associated with OCP use.
Background: Although many young investigators are interested in cardiovascular (CV) outcomes research, recent funding cutbacks may threaten the development of future leaders in this field. Methods & Results: From April-Nov 2014, we surveyed mentees and mentors to determine current training experiences of early CV outcomes investigators across the U.S. We contacted successful grantees of government agencies, members of professional organizations, and trainees within cardiovascular outcomes training programs by e-mail. There were 185/662 mentee and 76/541 mentor responses. Mentees were equally split by sex; most had completed training >3 yrs ago and were clinicians. Mentors were more likely female, mostly ≥20 yrs post-training, associate/ full professors, clinical, and mentoring 2-4 people. Over 80% mentees entered into training to be academicians and left with the same goal. Over 70% of mentees wanted to have >50% time for research in the future. Over 80% of mentors believed that future investigators would need >50% of their time dedicated to research efforts in order to be successful; 22% of mentors thought that future researchers needed more time than the mentors themselves had in their early careers. Most mentees (80%) reported that they were satisfied with their relationship with their mentor and had been given opportunities to develop independently. Mentors were more likely than mentees to report that funding cutbacks had negatively affected the ability to succeed (58% mentees vs. 84% mentors). Across funding mechanisms, mentees were more optimistic than mentors about securing funding (Figure). Both mentees and mentors reported greatest preparedness for job/career satisfaction (79% for both) and publications (84% vs. 92%) and least preparedness for financial futures (48% vs. 46%) and work-life balance (47% vs. 42%). Conclusions: Both mentees and mentors were optimistic about the future of cardiovascular outcomes research; however, they expressed pessimism regarding funding. Future studies should characterize the types of research that are currently being submitted and funded at different agencies to identify critical gaps and needs and to improve young investigators’ chances of obtaining independent funding.
Practice guidelines do not recommend use of an implantable cardioverter-defibrillator (ICD) for primary prevention in patients recovering from a myocardial infarction or coronary artery bypass graft surgery and those with severe heart failure symptoms or a recent diagnosis of heart failure.To determine the number, characteristics, and in-hospital outcomes of patients who receive a non-evidence-based ICD and examine the distribution of these implants by site, physician specialty, and year of procedure.Retrospective cohort study of cases submitted to the National Cardiovascular Data Registry-ICD Registry between January 1, 2006, and June 30, 2009.In-hospital outcomes.Of 111,707 patients, 25,145 received non-evidence-based ICD implants (22.5%). Patients who received a non-evidence-based ICD compared with those who received an evidence-based ICD had a significantly higher risk of in-hospital death (0.57% [95% confidence interval {CI}, 0.48%-0.66%] vs 0.18% [95% CI, 0.15%-0.20%]; P <.001) and any postprocedure complication (3.23% [95% CI, 3.01%-3.45%] vs 2.41% [95% CI, 2.31%-2.51%]; P <.001). There was substantial variation in non-evidence-based ICDs by site. The rate of non-evidence-based ICD implants was significantly lower for electrophysiologists (20.8%; 95% CI, 20.5%-21.1%) than nonelectrophysiologists (24.8% [95% CI, 24.2%-25.3%] for nonelectrophysiologist cardiologists; 36.1% [95% CI, 34.3%-38.0%] for thoracic surgeons; and 24.9% [95% CI, 23.8%-25.9%] for other specialties) (P<.001 for all comparisons). There was no clear decrease in the rate of non-evidence-based ICDs over time (24.5% [6908/28,233] in 2006, 21.8% [7395/33,965] in 2007, 22.0% [7245/32,960] in 2008, and 21.7% [3597/16,549] in 2009; P <.001 for trend from 2006-2009 and P = .94 for trend from 2007-2009).Among patients with ICD implants in this registry, 22.5% did not meet evidence-based criteria for implantation.
To review the performance characteristics of the instruments most commonly used to measure clinical outcomes in juvenile idiopathic arthritis (JIA), including global assessments, articular indices, functional/disability assessments, and quality of life measures.As part of an Agency for Healthcare Research and Quality comparative effectiveness review of antirheumatic drugs, we explored the characteristics of commonly used outcome measures for JIA. English-language studies of children with JIA were identified from Medline and Embase. Two independent reviewers screened titles and abstracts, with subsequent full-text review of studies selected based on predetermined criteria.We included 35 publications describing 34 unique studies and involving 14,831 patients. The Childhood Health Assessment Questionnaire (C-HAQ) was the most extensively studied instrument and had high reliability, but only moderate correlations with other indices of disease activity and poor responsiveness to change in disease status. The physician global assessment of disease activity (PGA) and articular indices had the strongest association with disease activity and were the most responsive to change. Measures of psychosocial function and quality of life were moderately associated with measures of disease activity, but were less responsive to changes in disease status.In children with JIA, no single instrument was superior in reliability or validity or in describing the impact of JIA. Although the C-HAQ has been extensively evaluated, the PGA and articular indices appear to have the highest responsiveness to change and, therefore, the highest potential for detecting important differences in treatment response.
Patients who have had an acute coronary syndrome (ACS) event have an increased risk for depression.To evaluate the diagnostic accuracy of depression screening instruments and to compare safety and effectiveness of depression treatments in adults within 3 months of an ACS event.MEDLINE, EMBASE, PsycINFO, CINAHL, and Cochrane Database of Systematic Reviews from January 2003 to August 2017, and a manual search of citations from key primary and review articles.English-language studies of post-ACS patients that evaluated the diagnostic accuracy of depression screening tools or compared the safety and effectiveness of a broad range of pharmacologic and nonpharmacologic depression treatments.2 investigators independently screened each article for inclusion; abstracted the data; and rated the quality, applicability, and strength of evidence.Evidence from 6 of the 10 included studies showed that a range of depression screening instruments produces acceptable levels of diagnostic sensitivity, specificity, and negative predictive values (70% to 100%) but low positive predictive values (below 50%). The Beck Depression Inventory-II was the most studied tool. A large study found that a combination of cognitive behavioral therapy (CBT) and antidepressant medication improved depression symptoms, mental health-related function, and overall life satisfaction more than usual care.Few studies, no evaluation of the influence of screening on clinical outcomes, and no studies addressing several clinical interventions of interest.Depression screening instruments produce diagnostic accuracy metrics that are similar in post-ACS patients and other clinical populations. Depression interventions have an uncertain effect on cardiovascular outcomes, but CBT combined with antidepressant medication produces modest improvement in psychosocial outcomes.Agency for Healthcare Research and Quality (PROSPERO: CRD42016047032).
Despite a paucity of high-quality evidence about benefits and harms, antipsychotic medication use among adolescents and young adults with bipolar disorder is increasing. The Patient-Centered Outcomes Research Institute tasked the Duke Evidence Synthesis Group with creating a prioritized agenda for research in this area that would incorporate the perspectives of relevant stakeholders. We identified a list of potential evidence gaps by reviewing existing literature and engaged a diverse group of 9 stakeholders to expand and refine this list. Using a forced-ranking prioritization method, stakeholders prioritized 10 of 23 potential evidence gaps as the most pressing for future research. These evidence gaps relate to 3 areas: the comparative effectiveness of intervention strategies, the effect of antipsychotics on patient-centered outcomes, and the influence of various patient characteristics on antipsychotic effectiveness. In addition to presenting these findings, we suggest appropriate study designs for addressing the stakeholder-prioritized research questions.
