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BMJ Open Jun 2018The maternal near-miss cases review (NMCR), a type of clinical audit, proved to be effective in improving quality of care and decreasing maternal mortality in...
Facilitators and barriers to the effective implementation of the individual maternal near-miss case reviews in low/middle-income countries: a systematic review of qualitative studies.
BACKGROUND
The maternal near-miss cases review (NMCR), a type of clinical audit, proved to be effective in improving quality of care and decreasing maternal mortality in low/middle-income countries (LMICs). However, challenges in its implementation have been described.
OBJECTIVES
Synthesising the evidence on facilitators and barriers to the effective implementation of NMCR in LMICs.
DESIGN
Systematic review of qualitative studies.
DATA SOURCES
MEDLINE, LILACS, Global Health Library, SCI-EXPANDED, SSCI, Cochrane library and Embase were searched in December 2017.
ELIGIBILITY CRITERIA FOR SELECTING STUDIES
Qualitative studies exploring facilitators and/or barriers of implementing NMCR in LMIC were included.
DATA EXTRACTION AND SYNTHESIS
Two independent reviewers extracted data, performed thematic analysis and assessed risk of bias.
RESULTS
Out of 25 361 papers retrieved, 9 studies from Benin, Brazil, Burkina Faso, Cote D'Ivoire, Ghana, Malawi, Morocco, Tanzania, Uganda could be included in the review. The most frequently reported barriers to NMCR implementation were the following: absence of national guidelines and local protocols; insufficient training on how to perform the audit; lack of leadership, coordination, monitoring and supervision; lack of resources and work overload; fear of blame and punishment; poor knowledge of evidenced-based medicine; hierarchical differences among staff and poor understating of the benefits of the NMCR. Major facilitators to NMCR implementation included: good leadership and coordination; training of all key staff; a good cultural environment; clear staff's perception on the benefits of conducting audit; patient empowerment and the availability of external support.
CONCLUSIONS
In planning the NMCR implementation in LMICs, policy-makers should consider actions to prevent and mitigate common challenges to successful NMCR implementation. Future studies should aim at documenting facilitators and barriers to NMCR outside the African Region.
Topics: Developing Countries; Female; Humans; Infant, Newborn; Maternal Mortality; Near Miss, Healthcare; Parturition; Poverty; Pregnancy; Qualitative Research; Quality of Health Care
PubMed: 29961025
DOI: 10.1136/bmjopen-2017-021281 -
PeerJ 2018Reward seeking and avoidance of punishment are key motivational processes. Brain-imaging studies often use the (MIDT) to evaluate motivational processes involved in...
BACKGROUND
Reward seeking and avoidance of punishment are key motivational processes. Brain-imaging studies often use the (MIDT) to evaluate motivational processes involved in maladaptive behavior. Although the bulk of research has been done on the MIDT reward events, little is known about the neural basis of avoidance of punishment. Therefore, we conducted a meta-analysis of brain activations during anticipation and receipt of monetary losses in healthy controls.
METHODS
All functional neuro-imaging studies using the MIDT in healthy controls were retrieved using PubMed, Google Scholar & EMBASE databases. Functional neuro-imaging data was analyzed using the Seed-based d Mapping Software.
RESULTS
Thirty-five studies met the inclusion criteria, comprising 699 healthy adults. In both anticipation and loss outcome phases, participants showed large and robust activations in the bilateral striatum, (anterior) insula, and anterior cingulate gyrus relatively to Loss > Neutral contrast. Although relatively similar activation patterns were observed during the two event types, they differed in the pattern of prefrontal activations: ventro-lateral prefrontal activations were observed during loss anticipation, while medial prefrontal activations were observed during loss receipt.
DISCUSSION
Considering that previous meta-analyses highlighted activations in the medial prefrontal cortex/anterior cingulate cortex, the anterior insula and the ventral striatum, the current meta-analysis highlighted the potential specificity of the ventro-lateral prefrontal regions, the median cingulate cortex and the amygdala in the loss events. Future studies can rely on these latter results to examine the neural correlates of loss processing in psychiatric populations characterized by harm avoidance or insensitivity to punishment.
PubMed: 29761060
DOI: 10.7717/peerj.4749 -
BMC Medical Ethics Apr 2018Forensic psychiatry is a particular subspecialty within psychiatry, dedicated in applying psychiatric knowledge and psychiatric training for particular legal purposes....
BACKGROUND
Forensic psychiatry is a particular subspecialty within psychiatry, dedicated in applying psychiatric knowledge and psychiatric training for particular legal purposes. Given that within the scope of forensic psychiatry, a third party usually intervenes in the patient-doctor relationship, an amendment of the traditional ethical principles seems justified.
RESULTS
Thus, 47 articles, two book chapters and the guidelines produced by the World Psychiatric Association, the American Association of Psychiatry and the Law, as well as by the Royal Australian and New Zealand College of psychiatrists, were analyzed. The review revealed that the ethics of correctional forensic psychiatry and those of legal forensic psychiatry do not markedly differ from each other, but they are incongruent in terms of implementation.
METHODS
In an effort to better understand which ethical principles apply to forensic psychiatry, a chronological review of the literature published from 1950 to 2015 was carried out.
CONCLUSION
The ethics of correctional forensic psychiatry are primarily deontological. The principle of justice translates into the principle of health care equivalence, the principle of beneficence into providing the best possible care to patients, and the principle of respect of autonomy into ensuring confidentiality and informed consent. The ethics of legal forensic psychiatry are rather consequentialist. In this latter setting, the principle of justice is mainly characterized by professionalism, the principle of beneficence by objectivity and impartiality, and the principle of respect of autonomy by informed consent. However, these two distinct fields of forensic psychiatry share in common the principle of non maleficence, defined as the non collaboration of the psychiatrist in any activity leading to inhuman and degrading treatment or to the death penalty.
Topics: Beneficence; Capital Punishment; Ethical Theory; Ethics, Medical; Forensic Psychiatry; Informed Consent; Jurisprudence; Moral Obligations; Personal Autonomy; Physician-Patient Relations; Principle-Based Ethics; Professionalism; Social Justice; Torture
PubMed: 29636102
DOI: 10.1186/s12910-018-0266-5 -
Campbell Systematic Reviews 2018This Campbell systematic review examines the impact of interventions to reduce exclusion from school. School exclusion, also known as suspension in some countries, is a...
UNLABELLED
This Campbell systematic review examines the impact of interventions to reduce exclusion from school. School exclusion, also known as suspension in some countries, is a disciplinary sanction imposed by a responsible school authority, in reaction to students' misbehaviour. Exclusion entails the removal of pupils from regular teaching for a period during which they are not allowed to be present in the classroom (in-school) or on school premises (out-of-school). In some extreme cases the student is not allowed to come back to the same school (expulsion). The review summarises findings from 37 reports covering nine different types of intervention. Most studies were from the USA, and the remainder from the UK. Included studies evaluated school-based interventions or school-supported interventions to reduce the rates of exclusion. Interventions were implemented in mainstream schools and targeted school-aged children from four to 18, irrespective of nationality or social background. Only randomised controlled trials are included. The evidence base covers 37 studies. Thirty-three studies were from the USA, three from the UK, and for one study the country was not clear. School-based interventions cause a small and significant drop in exclusion rates during the first six months after intervention (on average), but this effect is not sustained. Interventions seemed to be more effective at reducing some types of exclusion such as expulsion and in-school exclusion. Four intervention types - enhancement of academic skills, counselling, mentoring/monitoring, and skills training for teachers - had significant desirable effects on exclusion. However, the number of studies in each case is low, so this result needs to be treated with caution. There is no impact of the interventions on antisocial behaviour. Variations in effect sizes are not explained by participants' characteristics, the theoretical basis of the interventions, or the quality of the intervention. Independent evaluator teams reported lower effect sizes than research teams who were also involved in the design and/or delivery of the intervention.
PLAIN LANGUAGE SUMMARY
Some interventions - enhancement of academic skills, counselling, mentoring/monitoring, and skills training for teachers - appear to have significant effects on exclusion. Interventions to reduce school exclusion are intended to mitigate the adverse effects of this school sanction. Some approaches, namely those involving enhancement of academic skills, counselling, mentoring/monitoring and those targeting skills training for teachers, have a temporary effect in reducing exclusion. More evaluations are needed to identify the most effective types of intervention; and whether similar effects are also found in different countries. School exclusion is associated with undesirable effects on developmental outcomes. It increases the likelihood of poor academic performance, antisocial behavior, and poor employment prospects. This school sanction disproportionally affects males, ethnic minorities, those who come from disadvantaged economic backgrounds, and those with special educational needs.This review assesses the effectiveness of programmes to reduce the prevalence of exclusion. Included studies evaluated school-based interventions or school-supported interventions to reduce the rates of exclusion. Interventions were implemented in mainstream schools and targeted school-aged children from four to 18, irrespective of nationality or social background. Only randomised controlled trials are included.The evidence base covers 37 studies. Thirty-three studies were from the USA, three from the UK, and for one study the country was not clear.School-based interventions cause a small and significant drop in exclusion rates during the first six months after intervention (on average), but this effect is not sustained. Interventions seemed to be more effective at reducing some types of exclusion such as expulsion and in-school exclusion.Four intervention types - enhancement of academic skills, counselling, mentoring/ monitoring, and skills training for teachers - had significant desirable effects on exclusion. However, the number of studies in each case is low, so this result needs to be treated with caution.There is no impact of the interventions on antisocial behaviour.Variations in effect sizes are not explained by participants' characteristics, the theoretical basis of the interventions, or the quality of the intervention. Independent evaluator teams reported lower effect sizes than research teams who were also involved in the design and/or delivery of the intervention. School-based interventions are effective at reducing school exclusion immediately after, and for a few months after, the intervention (6 months on average). Four interventions presented promising and significant results in reducing exclusion, that is, enhancement of academic skills, counselling, mentoring/monitoring, skills training for teachers. However, since the number of studies for each sub-type of intervention was low, we suggest these results should be treated with caution.Most of the studies come from the USA. Evaluations are needed from other countries in which exclusion is common. Further research should take advantage of the possibility of conducting cluster-randomised controlled trials, whilst ensuring that the sample size is sufficiently large. The review authors searched for studies published up to December 2015. This Campbell systematic review was published in January 2018.
EXECUTIVE SUMMARY/ABSTRACT
Schools are important institutions of formal social control (Maimon, Antonaccio, & French, 2012). They are, apart from families, the primary social system in which individuals are socialised to follow specific codes of conduct. Violating these codes of conduct may result in some form of punishment. School punishment is normally accepted by families and students as a consequence of transgression, and in that sense school isoften the place where children are first introduced to discipline, justice, or injustice (Whitford & Levine-Donnerstein, 2014).A wide range of punishments may be used in schools, from verbal reprimands to more serious actions such as detention, fixed term exclusion or even permanent exclusion from the mainstream education system. It must be said that in some way, these school sanctions resemble the penal system and its array of alternatives to punish those that break the law.School exclusion, also known as suspension in some countries, is defined as a disciplinary sanction imposed by a responsible school authority, in reaction to students' misbehaviour. Exclusion entails the removal of pupils from regular teaching for a period during which they are not allowed to be present in the classroom or, in more serious cases, on school premises. Most of the available research has found that exclusion correlates with subsequent negative sequels on developmental outcomes. Exclusion or suspension of students is associated with failure within the academic curriculum, aggravated antisocial behaviour, and an increased likelihood of involvement with punitive social control institutions (i.e., the Juvenile Justice System). In the long-term, opportunities for training and employment seem to be considerably reduced for those who have repeatedly been excluded. In addition to these negative correlated outcomes, previous evidence suggest that the exclusion of students involves a high economic cost for taxpayers and society.Research from the last 20 years has concluded quite consistently that this disciplinary measure disproportionally targets males, ethnic minorities, those who come from disadvantaged economic backgrounds, and those presenting special educational needs. In other words, suspension affects the most vulnerable children in schools.Different programmes have attempted to reduce the prevalence of exclusion. Although some of them have shown promising results, so far, no comprehensive systematic review has examined these programmes' overall effectiveness. The main goal of the present research is to systematically examine the available evidence for the effectiveness of different types of school-based interventions aimed at reducing disciplinary school exclusion. Secondary goals include comparing different approaches and identifying those that could potentially demonstrate larger and more significant effects.The research questions underlying this project are as follows: Do school-based programmes reduce the use of exclusionary sanctions in schools?Are some school-based approaches more effective than others in reducing exclusionary sanctions?Do participants' characteristics (e.g., age, gender, ethnicity) affect the impact of school-based programmes on exclusionary sanctions in schools?Do characteristics of the interventions, implementation, and methodology affect the impact of school-based programmes on exclusionary sanctions in schools? The authors conducted a comprehensive search to locate relevant studies reporting on the impact of school-based interventions on exclusion from 1980 onwards. Twenty-seven different databases were consulted, including databases that contained both published and unpublished literature. In addition, we contacted researchers in the field of school-exclusion for further recommendations of relevant studies; we also assessed citation lists from previous systematic and narrative reviews and research reports. Searches were conducted from September 1 to December 1, 2015. The inclusion and exclusion criteria for manuscripts were defined before we started our searches. To be eligible, studies needed to have: evaluated school-based interventions or school-supported interventions intended to reduce the rates of suspension; seen the interventions as an alternative to exclusion; targeted school-aged children from four to 18 in mainstream schools irrespective of nationality or social background; and reported results of interventions delivered from 1980 onwards. In terms of methodological design, we included randomised controlled trialsonly, with at least one experimental group and onecontrol or placebo group. Initial searches produced a total of 42,749 references from 27 different electronic databases. After screening the title, abstract and key words, we kept 1,474 relevant hits. 22 additional manuscripts were identified through other sources (e.g., assessment of citation lists, contribution of authors). After removing duplicates, we ended up with a total of 517 manuscripts. Two independent coders evaluated each report, to determine inclusion or exclusion.The second round of evaluation excluded 472 papers, with eight papers awaiting classification, and 37 studies kept for inclusion in meta-analysis. Two independent evaluators assessed all the included manuscripts for risk of quality bias by using EPOC tool.Due to the broad scope of our targeted programmes, meta-analysis was conducted under a random-effect model. We report the impact of the intervention using standardised differences of means, 95% confidence intervals along with the respective forest plots. Sub-group analysis and meta-regression were used for examining the impact of the programme. Funnel plots and Duval and Tweedie's trim-and-fill analysis were used to explore the effect of publication bias. Based on our findings, interventions settled in school can produce a small and significant drop in exclusion rates (SMD=.30; .20 to .41; <.001). This means that those participating in interventions are less likely to be suspended than those allocated to control/placebo groups. These results are based on measures of impact collected immediately during the first six months after treatment (on average). When the impact was tested in the long-term (i.e., 12 or more months after treatment), the effects of the interventions were not sustained. In fact, there was a substantive reduction in the impact of school-based programmes (SMD=.15; 95%CI -.06 to .35), and it was no longer statistically significant.We ran analysis testing the impact of school-based interventions on different types of exclusion. Evidence suggests that interventions are more effective at reducing expulsion and in-school exclusion than out-of-school exclusion. In fact, the impact of intervention in out-of-school exclusion was close to zero and not statistically significant.Nine different types of school-based interventions were identified across the 37 studies included in the review. Four of them presented favourable and significant results in reducing exclusion (i.e., enhancement of academic skills, counselling, mentoring/monitoring, skills training for teachers). Since the number of studies for each sub-type of intervention was low, we suggest that results should be treated with caution.A priori defined moderators (i.e., participants' characteristics, the theoretical basis of the interventions, and quality of the intervention)showed not to be effective at explaining the heterogeneity present in our results. Among three post-hoc moderators, the role of the evaluator was found to be significant: independent evaluator teams reported lower effect sizes than research teams who were also involved in the design and/or delivery of the intervention.Two researchers independently evaluated the quality of the evidence involved in this review by using the EPOC tool. Most of the studies did not present enough information for the judgement of quality bias. The evidence suggests that school-based interventions are effective at reducing school exclusion immediately after, and for a few months after, the intervention. Some specific types of interventions show more promising and stable results than others, namely those involving mentoring/monitoring and those targeting skills training for teachers. However, based on the number of studies involved in our calculations, we suggest that results must be cautiously interpreted. Implications for policy and practice arising from our results are discussed.
PubMed: 37131379
DOI: 10.4073/csr.2018.1 -
MedEdPublish (2016) 2017This article was migrated. The article was marked as recommended. To increase the motivation of students at small group seminar education sessions, teachers and...
This article was migrated. The article was marked as recommended. To increase the motivation of students at small group seminar education sessions, teachers and institutions often revert to rewarding the prepared students and/or punishing those who did not prepare. How effective is that? We sought to find theoretical claims or disclaims for this policy from Self-Determination Theory, which is an important contemporary theory about motivation. SDT distinguishes intrinsic and extrinsic motivation and provides evidence for the use of rewards and punishments. The primary aim was to explore the effects of extrinsic rewards and negative incentives on the intrinsic motivation in the literature. A secondary goal was to provide practical tips for teachers to improve the motivation of medical students. Verbal rewards can increase the intrinsic motivation. Unexpected tangible and task-non-contingent tangible rewards appear to have no detrimental effect on the intrinsic motivation. All other expected tangible rewards and negative incentives, like threats and deadlines, have been found to undermine the intrinsic motivation. Autonomous self-regulated learning (intrinsic motivation, identified regulation and/or integrated regulation) is associated with high quality learning and well-being. Autonomous self-regulated learning is therefore the desired drive for learning and can be supported by a teacher via satisfying the needs for autonomy, competence and relatedness. Extrinsic rewards and negative incentives should be avoided as they both undermine the intrinsic motivation. Autonomous self-regulated learning leads to more effective learning. Several practical tips that support one of the three basic psychological needs are discussed. Most are relatively easy to apply and stimulate autonomous self-regulated learning.
PubMed: 38406451
DOI: 10.15694/mep.2017.000086 -
Journal of Preventive Medicine and... Mar 2017We performed a systematic review to assess and aggregate the available evidence on the frequency, expected effects, obstacles, and facilitators of disclosure of patient... (Review)
Review
OBJECTIVES
We performed a systematic review to assess and aggregate the available evidence on the frequency, expected effects, obstacles, and facilitators of disclosure of patient safety incidents (DPSI).
METHODS
We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for this systematic review and searched PubMed, Scopus, and the Cochrane Library for English articles published between 1990 and 2014. Two authors independently conducted the title screening and abstract review. Ninety-nine articles were selected for full-text reviews. One author extracted the data and another verified them.
RESULTS
There was considerable variation in the reported frequency of DPSI among medical professionals. The main expected effects of DPSI were decreased intention of the general public to file medical lawsuits and punish medical professionals, increased credibility of medical professionals, increased intention of patients to revisit and recommend physicians or hospitals, higher ratings of quality of care, and alleviation of feelings of guilt among medical professionals. The obstacles to DPSI were fear of medical lawsuits and punishment, fear of a damaged professional reputation among colleagues and patients, diminished patient trust, the complexity of the situation, and the absence of a patient safety culture. However, the factors facilitating DPSI included the creation of a safe environment for reporting patient safety incidents, as well as guidelines and education for DPSI.
CONCLUSIONS
The reported frequency of the experience of the general public with DPSI was somewhat lower than the reported frequency of DPSI among medical professionals. Although we identified various expected effects of DPSI, more empirical evidence from real cases is required.
Topics: Databases, Factual; Humans; Medical Errors; Patient Safety; Physicians
PubMed: 28372351
DOI: 10.3961/jpmph.16.105 -
Eye (London, England) Aug 2017PurposeTo identify the spectrum of non-vitreoretinal ocular injury due to child maltreatment.MethodsAll language search of MEDLINE, PsychINFO, EMBASE, AMED, Web of... (Review)
Review
UNLABELLED
PurposeTo identify the spectrum of non-vitreoretinal ocular injury due to child maltreatment.MethodsAll language search of MEDLINE, PsychINFO, EMBASE, AMED, Web of Science, and CINAHL databases, 1950-2015, was conducted.
INCLUSION CRITERIA
explicit confirmation of injury aetiology, age <18 years, examination conducted by an ophthalmologist. Exclusion: post-mortem data, organic diseases, review articles. Standardised critical appraisal and narrative synthesis was conducted of included publications by two independent reviewers.ResultsOf 1492 studies identified, 153 full texts were assessed, 49 underwent full review, resulting in five included studies: three case series and two case reports. The 26 included cases describe a wide variety of ocular, facial and skeletal injuries occurring as a consequence of child maltreatment. Ocular signs included periorbital oedema, chemosis, injection, abrasion, hyphaema, and cataract. Of interest all children that had suffered physical abuse with ocular injury had subconjunctival haemorrhages. Children presenting with abusive ocular injuries had a mean age of 13.9 months (range 1-68), while those who suffered violent corporal punishment were considerably older (mean 96 months). All cases, apart from severe corporal punishment, underwent screening for occult fractures, but neuroimaging only apparent in 2/5 eligible cases.ConclusionAlthough, the face is the most common site of abusive injury, there is a paucity of high-quality data on non-vitreoretinal ocular abusive injury. Thus, while subconjunctival haemorrhages are a potential sentinel injury of maltreatment, and may warrant further evaluation, the lack of large-scale published data limits our ability to highlight further specific characteristics of non-vitreoretinal ocular injury indicative of child abuse.
Topics: Adolescent; Child; Child Abuse; Child, Preschool; Eye Hemorrhage; Eye Injuries; Humans; Infant; Punishment
PubMed: 28338664
DOI: 10.1038/eye.2017.25 -
The Cochrane Database of Systematic... Aug 2016Corruption is the abuse or complicity in abuse, of public or private position, power or authority to benefit oneself, a group, an organisation or others close to... (Review)
Review
BACKGROUND
Corruption is the abuse or complicity in abuse, of public or private position, power or authority to benefit oneself, a group, an organisation or others close to oneself; where the benefits may be financial, material or non-material. It is wide-spread in the health sector and represents a major problem.
OBJECTIVES
Our primary objective was to systematically summarise empirical evidence of the effects of strategies to reduce corruption in the health sector. Our secondary objective was to describe the range of strategies that have been tried and to guide future evaluations of promising strategies for which there is insufficient evidence.
SEARCH METHODS
We searched 14 electronic databases up to January 2014, including: CENTRAL; MEDLINE; EMBASE; sociological, economic, political and other health databases; Human Resources Abstracts up to November 2010; Euroethics up to August 2015; and PubMed alerts from January 2014 to June 2016. We searched another 23 websites and online databases for grey literature up to August 2015, including the World Bank, the International Monetary Fund, the U4 Anti-Corruption Resource Centre, Transparency International, healthcare anti-fraud association websites and trial registries. We conducted citation searches in Science Citation Index and Google Scholar, and searched PubMed for related articles up to August 2015. We contacted corruption researchers in December 2015, and screened reference lists of articles up to May 2016.
SELECTION CRITERIA
For the primary analysis, we included randomised trials, non-randomised trials, interrupted time series studies and controlled before-after studies that evaluated the effects of an intervention to reduce corruption in the health sector. For the secondary analysis, we included case studies that clearly described an intervention to reduce corruption in the health sector, addressed either our primary or secondary objective, and stated the methods that the study authors used to collect and analyse data.
DATA COLLECTION AND ANALYSIS
One review author extracted data from the included studies and a second review author checked the extracted data against the reports of the included studies. We undertook a structured synthesis of the findings. We constructed a results table and 'Summaries of findings' tables. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of the evidence.
MAIN RESULTS
No studies met the inclusion criteria of the primary analysis. We included nine studies that met the inclusion criteria for the secondary analysis.One study found that a package of interventions coordinated by the US Department of Health and Human Services and Department of Justice recovered a large amount of money and resulted in hundreds of new cases and convictions each year (high certainty of the evidence). Another study from the USA found that establishment of an independent agency to investigate and enforce efforts against overbilling might lead to a small reduction in overbilling, but the certainty of this evidence was very low. A third study from India suggested that the impacts of coordinated efforts to reduce corruption through increased detection and enforcement are dependent on continued political support and that they can be limited by a dysfunctional judicial system (very low certainty of the evidence).One study in South Korea and two in the USA evaluated increased efforts to investigate and punish corruption in clinics and hospitals without establishing an independent agency to coordinate these efforts. It is unclear whether these were effective because the evidence is of very low certainty.One study from Kyrgyzstan suggested that increased transparency and accountability for co-payments together with reduction of incentives for demanding informal payments may reduce informal payments (low certainty of the evidence).One study from Germany suggested that guidelines that prohibit hospital doctors from accepting any form of benefits from the pharmaceutical industry may improve doctors' attitudes about the influence of pharmaceutical companies on their choice of medicines (low certainty of the evidence).A study in the USA, evaluated the effects of introducing a law that required pharmaceutical companies to report the gifts they gave to healthcare workers. Another study in the USA evaluated the effects of a variety of internal control mechanisms used by community health centres to stop corruption. The effects of these strategies is unclear because the evidence was of very low certainty.
AUTHORS' CONCLUSIONS
There is a paucity of evidence regarding how best to reduce corruption. Promising interventions include improvements in the detection and punishment of corruption, especially efforts that are coordinated by an independent agency. Other promising interventions include guidelines that prohibit doctors from accepting benefits from the pharmaceutical industry, internal control practices in community health centres, and increased transparency and accountability for co-payments combined with reduced incentives for informal payments. The extent to which increased transparency alone reduces corruption is uncertain. There is a need to monitor and evaluate the impacts of all interventions to reduce corruption, including their potential adverse effects.
Topics: Controlled Before-After Studies; Cross-Sectional Studies; Fraud; Germany; Guidelines as Topic; Health Care Sector; Humans; India; Kyrgyzstan; Law Enforcement; Reimbursement Mechanisms; Republic of Korea; Social Responsibility; United States
PubMed: 27528494
DOI: 10.1002/14651858.CD008856.pub2 -
The Cochrane Database of Systematic... Jan 2016Enuresis (bedwetting) affects up to 20% of five year-olds and 2% of adults. Although spontaneous remission often occurs, the social, emotional and psychological costs... (Review)
Review
BACKGROUND
Enuresis (bedwetting) affects up to 20% of five year-olds and 2% of adults. Although spontaneous remission often occurs, the social, emotional and psychological costs can be great. Tricyclics have been used to treat enuresis since the 1960s.
OBJECTIVES
To assess the effects of tricyclic and related drugs compared with other interventions for treating children with enuresis.
SEARCH METHODS
We searched the Cochrane Incontinence Group Specialised Trials Register (containing trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE in process, ClinicalTrials.gov, WHO ICTRP and handsearching of journals and conference proceedings), on 30 November 2015, and reference lists of relevant articles.
SELECTION CRITERIA
We included all randomised and quasi-randomised trials comparing a tricyclic or related drug with another intervention for treating enuresis. We also included combination therapies that included tricyclics. We excluded trials for treating daytime wetting.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed the quality of the eligible trials, and extracted data. We settled differences by discussion with a third review author.
MAIN RESULTS
Sixty-four trials met the inclusion criteria, involving 4071 children. The quality of many trials was poor, with comparisons addressed by single studies. Minor adverse effects were common, and reported in 30 trials. These included dizziness, headache, mood changes, gastrointestinal discomforts and neutropenia. More serious side-effects can occur but were not reported. Seven trials reported no adverse effects.Tricyclics are more effective than placebo, particularly for short-term outcomes. Compared to placebo, imipramine resulted in one fewer wet nights per week (mean difference (MD) -0.95, 95% confidence interval (CI) -1.40 to -0.50; 4 trials, 347 children), with fewer failing to achieve 14 consecutive dry nights (78% versus 95% for placebo, RR 0.74, 95% CI 0.61 to 0.90; 12 trials, 831 children). Amitriptyline and desipramine were more effective than placebo, but nortriptyline and mianserin showed no difference. Most tricyclics did not have a sustained effect after ceasing treatment, with 96% wetting at follow-up for imipramine versus 97% for placebo.Imipramine combined with oxybutynin is also more effective than placebo, with 33% failing to achieve 14 consecutive dry nights at the end of treatment versus 78% for placebo (RR 0.43, 95% CI 0.23 to 0.78; 1 trial, 47 children) and 45% wetting at follow-up versus 79% for placebo (RR 0.58, 95% CI 0.34 to 0.99; 1 trial, 36 children).There was insufficient evidence to judge the effect between different doses of tricyclics, and between different tricyclics. Treatment outcomes between tricyclic and desmopressin were similar, but were mixed when tricyclic was compared with an anticholinergic. However, when imipramine was compared with desmopressin plus oxybutynin (1 trial, 45 children), the combination therapy was more effective, with one fewer wet nights per week (MD 1.07, 95% CI 0.06 to 2.08) and 36% failing to achieve 14 consecutive dry nights versus 87% for imipramine (RR 2.39, 95% CI 1.35 to 4.25). Tricyclics were also more effective or showed no difference in response when compared to other drugs which are no longer used for enuresis.Tricyclics were less effective than alarms. Although there was no difference in the number of wet nights, 67% failed to achieve 14 consecutive dry nights for imipramine versus only 17% for alarms (RR 4.00, 95% CI 1.06 to 15.08; 1 trial, 24 children). Alarm therapy also had a more sustained effect after ceasing treatment with 100% on imipramine versus 58% on alarms wetting at follow-up (RR 1.67, 95% CI 1.03 to 2.69; 1 trial, 24 children).Imipramine was more effective than simple behavioural therapies during treatment, with one fewer wet nights per week compared with star chart plus placebo (MD -0.80, 95% CI -1.33 to -0.27; 1 trial, 250 children). At follow-up 40% were wet with imipramine versus 80% with fluids and avoiding punishment (RR 0.50, 95% CI 0.28 to 0.89; 1 trial, 40 children). However, imipramine was less effective than complex behavioural therapies, with 61% failing to achieve 14 consecutive dry nights for imipramine versus 33% for the three-step programme (RR 1.83, 95% CI 1.08 to 3.12; 1 trial, 72 children) and 16% for the three-step programme combined with motivational therapy and computer-led education (RR 3.91, 95% CI 2.30 to 6.66; 1 trial, 132 children) at the end of treatment, with similar results at follow-up.Tricyclics were more effective than restricted diet, with 99% failing to achieve 14 consecutive dry nights versus 84% for imipramine (RR 0.84, 95% CI 0.75 to 0.93; 1 trial, 147 children).There was insufficient evidence to judge the effect of tricyclics compared to the other miscellaneous interventions studied.At the end of treatment there were about two fewer wet nights for imipramine plus oxybutynin compared with imipramine monotherapy (MD -2.10, 95% CI -2.99 to -1.21; 1 trial, 63 children) and 48% on imipramine plus oxybutynin failed to achieve 14 consecutive dry nights compared with 74% on imipramine monotherapy (RR 0.68, 95% CI 0.50 to 0.92; 2 trials, 101 children). At follow-up, 45% on imipramine plus oxybutynin were wetting versus 83% on imipramine monotherapy (RR 0.55, 95% CI 0.32 to 0.92; 1 trial, 36 children).When imipramine combined with desmopressin was compared with imipramine monotherapy, there was no difference in outcomes. However, when imipramine plus desmopressin was compared with desmopressin monotherapy, the combination was more effective, with 15% not achieving 14 consecutive dry nights at the end of treatment for imipramine plus desmopressin versus 40% for desmopressin monotherapy (RR 0.38, 95% CI 0.17 to 0.83; 1 trial, 86 children). Tricyclics combined with alarm therapy were not more effective than alarm monotherapy, alarm combined with desmopressin or alarm combined with nortriptyline. The addition of a tricyclic to other behavioural therapies did not alter treatment response.
AUTHORS' CONCLUSIONS
There was evidence that tricyclics are effective at reducing the number of wet nights during treatment, but do not have a sustained effect after treatment stops, with most children relapsing. In contrast, there was evidence that alarm therapy has better short- and long-term outcomes. There was some evidence that tricyclics combined with anticholinergics may be more effective that tricyclic monotherapy.
Topics: Antidepressive Agents, Tricyclic; Child; Child, Preschool; Clinical Alarms; Enuresis; Humans; Randomized Controlled Trials as Topic
PubMed: 26789925
DOI: 10.1002/14651858.CD002117.pub2 -
Clinical Child and Family Psychology... Dec 2015Over the last decade, several candidate genes (i.e., MAOA, DRD4, DRD2, DAT1, 5-HTTLPR, and COMT) have been extensively studied as potential moderators of the detrimental... (Review)
Review
Over the last decade, several candidate genes (i.e., MAOA, DRD4, DRD2, DAT1, 5-HTTLPR, and COMT) have been extensively studied as potential moderators of the detrimental effects of postnatal family adversity on child externalizing behaviors, such as aggression and conduct disorder. Many studies on such candidate gene by environment interactions (i.e., cG × E) have been published, and the first part of this paper offers a systematic review and integration of their findings (n = 53). The overview shows a set of heterogeneous findings. However, because of large differences between studies in terms of sample composition, conceptualizations, and power, it is difficult to determine if different findings indeed illustrate inconsistent cG × E findings or if findings are simply incomparable. In the second part of the paper, therefore, we argue that one way to help resolve this problem is the development of theory-driven a priori hypotheses on which biopsychosocial mechanisms might underlie cG × E. Such a theoretically based approach can help us specify our research strategies, create more comparable findings, and help us interpret different findings between studies. In accordance, we describe three possible explanatory mechanisms, based on extant literature on the concepts of (1) emotional reactivity, (2) reward sensitivity, and (3) punishment sensitivity. For each mechanism, we discuss the link between the putative mechanism and externalizing behaviors, the genetic polymorphism, and family adversity. Possible research strategies to test these mechanisms, and implications for interventions, are discussed.
Topics: Child; Child Abuse; Child Behavior Disorders; Gene-Environment Interaction; Humans
PubMed: 26537239
DOI: 10.1007/s10567-015-0196-4