Screening for gestational diabetes : a systematic review and economic evaluation

Background Screening for gestational diabetes mellitus (GDM) has been controversial, with some expert bodies advising universal screening, others selective screening, and yet others advising against screening at all. This has partly been a result of debate about the definition of GDM, and partly because of the profusion of different tests available, both for screening and definite diagnosis. In the UK, there is no national policy on screening, and a variety of practices exist in different parts of the country. There have also been doubts about the treatment of GDM, and particularly about management of minor degrees of glucose elevation, which are better described as glucose intolerance rather than true diabetes. Objectives To provide an updated review of current knowledge, to clarify research needs, and to assist with policy making in the interim, pending future research. Methods A literature review was carried out, with a particular focus on screening methods and costs, and an appraisal of screening for GDM against the criteria for assessing screening programmes used by the UK National Screening Committee (NSC). Results There is still debate about what is meant by GDM – the threshold for diagnosis is not soundly based; the terms GDM and impaired glucose tolerance are not used in a standard fashion in pregnancy; there is almost certainly a continuum of risk to the baby, rather than there being separate normal and abnormal groups; and the key risk factor in most women may be maternal overweight, with glucose intolerance being an associate of that. In addition there are some rare genetic conditions, which affect a few women, such as glucokinase and hepatic nuclear factor disorders. GDM is usually defined according to divergence from normal glucose levels, but glucose levels are usually raised in pregnancy, and so diagnosis by normal levels in non-pregnant women may misclassify many normal pregnant women as abnormal. This may lead to anxiety and the inconvenience of extra investigations and ‘disease’ care. The Caesarean section rate appears to be increased by the diagnosis alone. Ideally, the condition should be defined by the incidence of adverse effects. However, the most common reported complication of GDM is ‘macrosomia’ in the baby. This is usually defined by arbitrary weight cut-offs (usually a birth weight of 4000 g, but sometimes 4500 g), but such neat thresholds fail to distinguish between larger than average healthy babies and those that have the abnormal growth patterns associated with high insulin levels in the womb. Screening for GDM fails to meet some of the NSC criteria. A number of screening tests have been used but some, such as glycosylated haemoglobin and fructosamine, have proved unsatisfactory and can be discarded. Others, such as urine testing or random blood glucose, are far from satisfactory, although they may be cheap to do. There is marked international variation. Risk factors such as weight, age and family history are useful for selective screening but some patients with GDM would be missed. Fasting plasma glucose (FPG) is convenient and reliable, but some pregnant women have normal fasting levels but raised levels of glucose after meals, and would be missed by screening based on FPG alone. Glucose challenge tests (GCTs) are based on glucose levels after a glucose drink, but also have shortcomings. The definitive diagnosis is usually by oral glucose tolerance test (OGTT), but the glucose load and timing vary in different countries; taking a 75 g glucose load is unnatural, makes some women sick, and the reproducibility of the test is poor. More natural methods such as test meals have been used, but not widely. Conclusions Interim conclusions There are clearly some women whose glucose levels rise sufficiently in pregnancy to cause harm to their babies. However, there are also many women with lower levels of glucose intolerance whose babies are not at risk, but who may suffer anxiety and inconvenience as a result of being classed as abnormal. On balance, the present evidence suggests that we should not have universal screening, but a highly selective policy, based on age and overweight. The best test at present, for those deemed to need testing, is probably the GCT, preferably combined with an FPG. The benefits of a follow-up OGTT are doubtful

The clinical and cost-effectiveness of patient education models for diabetes : a systematic review and economic evaluation

Description of the proposed service This systematic review examines the clinical and cost-effectiveness of patient education models for adults with Type 1 or Type 2 diabetes. Epidemiology and background Diabetes mellitus (diabetes) is characterised by a state of chronic hyperglycaemia (raised blood sugar). There are two main types of diabetes: Type 1 and Type 2. Type 1 diabetes is an autoimmune condition involving a process of destruction of the beta cells of the pancreas, leading to severe insulin deficiency. About one-fifth of patients with diabetes in England and Wales have Type 1 diabetes. Type 2 diabetes is characterised by insulin resistance and relative insulin deficiency and is linked to being overweight or obese, and to physical inactivity. Type 2 diabetes primarily affects people aged over 40 years. The basic target in the treatment of diabetes is the normalisation of blood glucose levels. Poor control of diabetes can in the short term result in diabetic ketoacidosis, a serious and potentially fatal condition, and in the long term can increase the risk of complications such as diabetic retinopathy and nephropathy. However, studies have shown that good diabetic control is associated with a reduced risk of these complications. Diabetic control is affected by both lifestyle factors such as diet, and by pharmacological treatments, and the management of diabetes is largely the responsibility of patients. A key component in empowering patients to manage their own diabetes is education. Education of patients with diabetes is considered a fundamental aspect of diabetes care and aims to empower patients by improving knowledge and skills. Structured educational programmes for diabetes self-management are often multifaceted interventions providing patients with information not only about diabetes but also management issues such as diet, exercise, self-monitoring of blood glucose and medication use. Methods A systematic review of the literature and an economic evaluation were undertaken. Data sources Electronic databases were searched, including the Cochrane Library, MEDLINE, EMBASE, PubMed, Science Citation Index, Web of Science Proceedings, DARE and HTA databases, PsychINFO, CINAHL, NHS Economic Evaluation Database and EconLit. References of all retrieved articles were checked for relevant studies, and experts were contacted for advice and peer review and to identify additional published and unpublished references. Sponsor submissions to the National Institute for Clinical Excellence were reviewed. Study selection Studies were included if they fulfilled the following criteria: Interventions: educational interventions compared with usual care or another educational intervention. Participants: adults with Type 1 or Type 2 diabetes mellitus. Outcomes: must report glycated haemoglobin, hypoglycaemic episodes, diabetic complications or quality of life. Other reported outcomes from included studies were discussed. Evaluation of outcomes >12 months from inception of intervention. Design: randomised clinical trials (RCTs), and controlled clinical trial (CCTs) with a concurrent control were included. Reporting: studies were only included if they reported sufficient detail of the intervention to be reproducible (e.g. topics covered, who provided the education, how many sessions were available). Studies in non-English language or available only as abstracts were excluded. Titles and abstracts were checked by two reviewers. Full texts of selected studies were assessed for inclusion by one reviewer and checked by a second. Differences in opinion were resolved through discussion. Data extraction and quality assessment Data extraction and quality assessment were undertaken by one reviewer and checked by a second, with any disagreement resolved through discussion involving a third reviewer if necessary. The quality of included studies was assessed in accordance with Centre for Reviews and Dissemination Report 4. Data synthesis Data on clinical effectiveness were synthesised through a narrative review with tabulation of results from included studies. Studies were too diverse to be combined in a meta-analysis. Cost-effectiveness analyses were reported in a narrative review. Number and quality of studies Searches identified 24 studies comparing education with either a control group or with another educational intervention. These were 18 RCTs and six CCTs. Four studies included adults with Type 1 diabetes, 16 studies included adults with Type 2 diabetes and four studies included adults with either Type 1 or Type 2 diabetes. The quality of reporting and methodology of the studies was generally poor by today’s standards with only two RCTs reporting adequate randomisation procedures and none demonstrating adequate allocation concealment. Economic evaluations Literature searches identified only two studies reporting cost-effectiveness results: one cost-utility analysis and one cost-effectiveness analysis using intermediate outcomes only. Summary of benefits Studies of education in Type 1 diabetes suggest that education programmes offered as a part of intensified treatment interventions can result in significant and long-lasting improvements in metabolic control and reductions in complications. These are studies in which education is part of a package of care also including treatment changes (for example diet and insulin) and therefore it is not possible to draw conclusions about potential effects of education per se in Type 1 diabetes. Diverse educational programmes in Type 2 diabetes did not yield consistent results. Although some trials reported significant improvements in metabolic control and/or quality of life or other psychological outcomes, many others did not report significant effects of educational interventions. No clear characterisation is possible as to what features of education may be beneficial in this patient group. Studies that included patients with either Type 1 or Type 2 diabetes also produced mixed results with only poorer quality studies reporting significant effects. Costs Literature searches identified a small number of studies offering cost data in relation to patient education models. These were all studies undertaken outside the UK and they covered a variety of methodologies. We are not able to generalise from these studies as to the cost-effectiveness of patient education models. Patient education models will predominantly consist of direct costs for resource inputs to particular education packages, for example staff time (diabetes specialist nurse, dietitian and/or consultant) and education materials. The Dose Adjustment for Normal Eating (DAFNE) intervention is estimated to cost approximately £545 per person attending. Costs per life year gained Owing to the absence of accurate data on health outcomes, we are not able to provide cost-effectiveness summary statistics. The evidence base does indicate that improved glycaemic control is likely to have a positive impact on the incidence of long-term diabetic complications. Therefore, where the costs associated with patient education are assumed to be in the region of £500–600 per patient, the benefits over time would have to be very modest to offer an attractive cost-effectiveness profile for the intervention. The submission from the DAFNE study group predicts a scenario in which the DAFNE intervention results in cost savings and added health benefits over time, when compared with usual practice. Implications The main implication for the NHS would be staff time, particularly of diabetes specialist nurses, but also dietitians. Provision of increased education may be hindered by a shortage of trained specialist nurses, which will take some years to resolve. Future research needs The paucity of high-quality trials that have tested education per se in diabetes reveals a need for more research. Such research should focus on RCTs with clear designs based on explicit hypotheses and with a range of outcomes evaluated after long follow-up intervals. In order to draw conclusions about the effects of education alone, such trials should manipulate only education rather than confounding education with other factors

The effectiveness of diagnostic tests for the assessment of shoulder pain due to soft tissue disorders : a systematic review

Objectives To evaluate the evidence for the effectiveness and cost-effectiveness of the newer diagnostic imaging tests as an addition to clinical examination and patient history for the diagnosis of soft tissue shoulder disorders. Data sources Literature was identified from several sources including general medical databases. Review methods Studies were identified that evaluated clinical examination, ultrasound, magnetic resonance imaging (MRI), or magnetic resonance arthrography (MRA) in patients suspected of having soft tissue shoulder disorders. Outcomes assessed were clinical impingement syndrome or rotator cuff tear (full, partial or any). Only cohort studies were included. The methodological quality of included test accuracy studies was assessed using a formal quality assessment tool for diagnostic studies and the extraction of study findings was conducted in duplicate using a pre-designed and piloted data extraction form to avoid any errors. For each test, sensitivity, specificity and positive and negative likelihood ratios with 95% confidence intervals were calculated for each study. Where possible pooled estimates of sensitivity, specificity and likelihood ratios were calculated using random effects methods. Potential sources of heterogeneity were investigated by conducting subgroup analyses. Results In the included studies, the prevalence of rotator cuff disorders was generally high, partial verification of patients was common and in many cases patients who were selected retrospectively because they had undergone the reference test. Sample sizes were generally very small. Reference tests were often inappropriate with many studies using arthrography alone, despite problems with its sensitivity. For clinical assessment, 10 cohort studies were found that examined either the accuracy of individual tests or clinical examination as a whole: individual tests were either good at ruling out rotator cuff tears when negative (high sensitivity) or at ruling in such disorders when positive (high specificity), but small sample sizes meant that there was no conclusive evidence. Ultrasound was investigated in 38 cohort studies and found to be most accurate when used for the detection of full-thickness tears; sensitivity was lower for detection of partial-thickness tears. For MRI, 29 cohort studies were included. For full-thickness tears, overall pooled sensitivities and specificities were fairly high and the studies were not statistically heterogeneous; however for the detection of partial-thickness rotator cuff tears, the pooled sensitivity estimate was much lower. The results from six MRA studies suggested that it may be very accurate for detection of full-thickness rotator cuff tears, although its performance for the detection of partial-thickness tears was less consistent. Direct evidence for the performance of one test compared with another is very limited. Conclusions The results suggest that clinical examination by specialists can rule out the presence of a rotator cuff tear, and that either MRI or ultrasound could equally be used for detection of full-thickness rotator cuff tears, although ultrasound may be better at picking up partial tears. Ultrasound also may be more cost-effective in a specialist hospital setting for identification of full-thickness tears. Further research suggestions include the need for large, well-designed, prospective studies of the diagnosis of shoulder pain, in particular a follow-up study of patients with shoulder pain in primary care and a prospective cohort study of clinical examination, ultrasound and MRI, alone and/or in combination

Parent-only interventions for childhood overweight or obesity in children aged 5 to 11 years

Background: Child and adolescent overweight and obesity have increased globally, and are associated with short- and long-term health consequences.Objectives: To assess the efficacy of diet, physical activity and behavioural interventions delivered to parents only for the treatment of overweight and obesity in children aged 5 to 11 years.Search methods: We performed a systematic literature search of databases including the Cochrane Library,MEDLINE, EMBASE, PsycINFO, CINAHL and LILACS as well trial registers.We checked references of identified trials and systematic reviews.We applied no language restrictions. The date of the last search was March 2015 for all databases.Selection criteria: We selected randomised controlled trials (RCTs) of diet, physical activity and behavioural interventions delivered to parents only for treating overweight or obesity in children aged 5 to 11 years.Data collection and analysis: Two review authors independently assessed trials for risk of bias and evaluated overall study quality using the GRADE instrument. Where necessary, we contacted authors for additional information.Main results: We included 20 RCTs, including 3057 participants. The number of participants ranged per trial between 15 and 645. Follow-up ranged between 24 weeks and two years. Eighteen trials were parallel RCTs and two were cluster RCTs. Twelve RCTs had two comparisons and eight RCTs had three comparisons. The interventions varied widely; the duration, content, delivery and follow-up of the interventions were heterogeneous. The comparators also differed. This review categorised the comparisons into four groups: parent-only versus parent-child, parent-only versus waiting list controls, parent-only versus minimal contact interventions and parent-only versus other parent-only interventions. Trial quality was generally low with a large proportion of trials rated as high risk of bias on individual risk of bias criteria. In trials comparing a parent-only intervention with a parent-child intervention, the body mass index (BMI) z score change showed a mean difference (MD) at the longest follow-up period (10 to 24 months) of -0.04 (95% confidence interval (CI) -0.15 to 0.08); P = 0.56; 267 participants; 3 trials; low quality evidence. In trials comparing a parent-only intervention with a waiting list control, the BMI z score change in favour of the parent-only intervention at the longest follow-up period (10-12 months) had an MD of -0.10 (95% CI -0.19 to -0.01); P = 0.04; 136 participants; 2 trials; low quality evidence. BMI z score change of parent-only interventions when compared with minimal contact control interventions at the longest follow-up period (9 to 12 months) showed an MD of 0.01 (95% CI -0.07 to 0.09); P = 0.81; 165 participants; 1 trial; low quality evidence. There were few similarities between interventions and comparators across the included trials in the parent-only intervention versus other parent-only interventions and we did not pool these data. Generally, these trials did not show substantial differences between their respective parent-only groups on BMI outcomes. Other outcomes such as behavioural measures, parent-child relationships and health-related quality of life were reported inconsistently. Adverse effects of the interventions were generally not reported, two trials stated that there were no serious adverse effects. No trials reported on all-cause mortality, morbidity or socioeconomic effects. All results need to be interpreted cautiously because of their low quality, the heterogeneous interventions and comparators, and the high rates of non-completion.Authors’ conclusions: Parent-only interventions may be an effective treatment option for overweight or obese children aged 5 to 11 years when compared with waiting list controls. Parent-only interventions had similar effects compared with parent-child interventions and compared with those with minimal contact controls. However, the evidence is at present limited; some of the trials had a high risk of bias with loss to follow-up being a particular issue and there was a lack of evidence for several important outcomes. The systematic review has identified 10 ongoing trials that have a parent-only arm, which will contribute to future updates. These trials will improve the robustness of the analyses by type of comparator, and may permit subgroup analysis by intervention component and the setting. Trial reports should provide adequate details about the interventions to be replicated by others. There is a need to conduct and report cost effectiveness analyses in future trials in order to establish whether parent-only interventions are more cost-effective than parent-child interventions

Splitting of the Dipole and Spin-Dipole Resonances

Cross sections for the 90,92,94Zr(p,n) reactions were measured at energies of 79.2 and 119.4 MeV. A phenomenological model was developed to describe the variation with bombarding energy of the position of the L=1 peak observed in these and other (p,n) reactions. The model yields the splitting between the giant dipole and giant spin dipole resonances. Values of these splittings are obtained for isotopes of Zr and Sn and for 208Pb.Comment: 14 pages, 4 figure

Clinical effectiveness and cost-effectiveness of immediate angioplasty for acute myocardial infarction : systematic review and economic evaluation

Background The blockage of a coronary artery (coronary thrombosis) can lead to a heart attack (acute myocardial infarction). There are several ways of trying to overcome this blockage. The methods include drug treatment to dissolve the clot (thrombolysis) and physical intervention, either by passing a catheter into the affected artery [angioplasty or percutaneous coronary intervention (PCI)], or bypassing the blocked section by cardiac surgery [coronary artery bypass grafting (CABG)]. Thrombolysis can be given in the community before the patient is sent to hospital, or delayed until after admission. Prehospital thrombolysis is not common in the UK. Immediate angioplasty is not routinely available in the UK at present; it is much more common in the USA. Objectives To review the clinical evidence comparing immediate angioplasty with thrombolysis, and to consider whether it would be cost-effective. Methods This report was based on a systematic review of the evidence of clinical effectiveness and an economic analysis of cost-effectiveness based on the clinical review and on cost data from published sources and de novo data collection. Data sources The search strategy searched six electronic databases (including Medline, Cochrane Library and EMBASE), with English-language limits, for the periods up to December 2002. Bibliographies of related papers were assessed for relevant studies and experts contacted for advice and peer review, and to identify additional published and unpublished references. Study selection For clinical effectiveness, a comprehensive review of randomised controlled trials (RCTs) was used for efficacy, and a selection of observational studies such as case series or audit data for effectiveness safety in routine practice. RCTs of thrombolysis were used to assess the relative value of prehospital and hospital thrombolysis. Observational studies were used to assess the representativeness of patients in the RCTs, and to determine whether different groups have different capacity to benefit. They were used to assess the implications of wider diffusion of the technology away from major centres. Data extraction Data extraction and quality assessment were undertaken by one reviewer and checked by a second reviewer, with any disagreements resolved through discussion. The quality of systematic reviews, RCTs, controlled clinical trials and economic studies was assessed using criteria recommended by the NHS Centre for Reviews and Dissemination (University of York). Study synthesis Clinical effectiveness was synthesised through a narrative review with full tabulation of results of all included studies and a meta-analysis to provide a precise estimate of absolute clinical benefit. Consideration was given to the effect of the growing use of stents. The economic modelling adopted an NHS perspective to develop a decision-analytical model of cost-effectiveness focusing on opportunity costs over the short term (6 months). Results and conclusion Number and quality of studies, and summary of benefits There were several good-quality systematic reviews, including a Cochrane review, as well as an individual patient meta-analysis and a number of recent trials not included in the reviews. The results were consistent in showing an advantage of immediate angioplasty over hospital thrombolysis. The updated meta-analysis showed that mortality is reduced by about one-third, from 7.6% to 4.9% in the first 6 months, and by about the same in studies of up to 24 months. Reinfarction is reduced by over half, from 7.6% to 3.1%. Stroke is reduced by about two-thirds, from 2.3% with thrombolysis to 0.7% with PCI, with the difference being due to haemorrhagic stroke. The need for CABG is reduced by about one-third, from 13.2% to 8.4%. Caution is needed in interpreting the older trials, as changes such as an increase in stenting and the use of the glycoprotein IIb/IIa inhibitors may improve the results of PCI. There is little evidence comparing prehospital thrombolysis with immediate PCI. One good quality study from France showed that prehospital thrombolysis with PCI in those in whom thrombolysis failed was as good as universal PCI. Research on thrombolysis followed by PCI, known as facilitated PCI, is underway, but results are not yet available. Further caveats are needed. Trials may be done in select centres and results may not be as good in lower volume centres, or out of normal working hours. In addition, much of the marginal mortality benefit of PCI over hospital thrombolysis may be lost if door-to-balloon time were more than 1 hour longer than door-to-needle time. Conversely, within the initial 6 hours, the later patients present, the greater the relative advantage of PCI. Cost-effectiveness If both interventions were routinely available, the economic analysis favours PCI, given the assumptions of the model. Results suggest that PCI is more cost-effective than thrombolysis, providing additional benefits in health status at some extra cost and an incremental cost per unit change in health status under the £30,000 threshold in most instances. In the longer term, the cost difference is expected to be reduced because of higher recurrence and reintervention rates among those who had thrombolysis. The model is not particularly sensitive to variations in probabilities from the clinical effectiveness analysis. However, very few units in England could offer a routine immediate PCI service at present, and there would be considerable resource implications of setting up such services. Without a detailed survey of existing provision, it is not possible to quantify the implications, but they include both capital and revenue: an increase in catheter laboratory provision and running costs. The greatest problem would be staffing, and that would take some years to resolve. A gradual incrementalist approach based on clinical networks, with transfer to centres able to offer PCI, could be used. In rural areas, one option could be to promote an increase in prehospital thrombolysis, with PCI for thrombolysis failures. Need for further research There is a need for economic data on the long-term consequences of the treatment, the quality of life of patients after treatment and the effects of PCI following thrombolysis failure

Diet, physical activity and behavioural interventions for the treatment of overweight or obese adolescents aged 12 to 17 years

Adolescent overweight and obesity has increased globally, and can be associated with short- and long-term health consequences. Modifying known dietary and behavioural risk factors through behaviour changing interventions (BCI) may help to reduce childhood overweight and obesity. This is an update of a review published in 2009. To assess the effects of diet, physical activity and behavioural interventions for the treatment of overweight or obese adolescents aged 12 to 17 years. We performed a systematic literature search in: CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, LILACS, and the trial registers ClinicalTrials.gov and ICTRP Search Portal. We checked references of identified studies and systematic reviews. There were no language restrictions. The date of the last search was July 2016 for all databases. We selected randomised controlled trials (RCTs) of diet, physical activity and behavioural interventions for treating overweight or obesity in adolescents aged 12 to 17 years. Two review authors independently assessed risk of bias, evaluated the overall quality of the evidence using the GRADE instrument and extracted data following the guidelines of the Cochrane Handbook for Systematic Reviews of Interventions. We contacted trial authors for additional information. We included 44 completed RCTs (4781 participants) and 50 ongoing studies. The number of participants in each trial varied (10 to 521) as did the length of follow-up (6 to 24 months). Participants ages ranged from 12 to 17.5 years in all trials that reported mean age at baseline. Most of the trials used a multidisciplinary intervention with a combination of diet, physical activity and behavioural components. The content and duration of the intervention, its delivery and the comparators varied across trials. The studies contributing most information to outcomes of weight and body mass index (BMI) were from studies at a low risk of bias, but studies with a high risk of bias provided data on adverse events and quality of life.The mean difference (MD) of the change in BMI at the longest follow-up period in favour of BCI was -1.18 kg/m(2) (95% confidence interval (CI) -1.67 to -0.69); 2774 participants; 28 trials; low quality evidence. BCI lowered the change in BMI z score by -0.13 units (95% CI -0.21 to -0.05); 2399 participants; 20 trials; low quality evidence. BCI lowered body weight by -3.67 kg (95% CI -5.21 to -2.13); 1993 participants; 20 trials; moderate quality evidence. The effect on weight measures persisted in trials with 18 to 24 months' follow-up for both BMI (MD -1.49 kg/m(2) (95% CI -2.56 to -0.41); 760 participants; 6 trials and BMI z score MD -0.34 (95% CI -0.66 to -0.02); 602 participants; 5 trials).There were subgroup differences showing larger effects for both BMI and BMI z score in studies comparing interventions with no intervention/wait list control or usual care, compared with those testing concomitant interventions delivered to both the intervention and control group. There were no subgroup differences between interventions with and without parental involvement or by intervention type or setting (health care, community, school) or mode of delivery (individual versus group).The rate of adverse events in intervention and control groups was unclear with only five trials reporting harms, and of these, details were provided in only one (low quality evidence). None of the included studies reported on all-cause mortality, morbidity or socioeconomic effects.BCIs at the longest follow-up moderately improved adolescent's health-related quality of life (standardised mean difference 0.44 ((95% CI 0.09 to 0.79); P = 0.01; 972 participants; 7 trials; 8 comparisons; low quality of evidence) but not self-esteem.Trials were inconsistent in how they measured dietary intake, dietary behaviours, physical activity and behaviour. We found low quality evidence that multidisciplinary interventions involving a combination of diet, physical activity and behavioural components reduce measures of BMI and moderate quality evidence that they reduce weight in overweight or obese adolescents, mainly when compared with no treatment or waiting list controls. Inconsistent results, risk of bias or indirectness of outcome measures used mean that the evidence should be interpreted with caution. We have identified a large number of ongoing trials (50) which we will include in future updates of this review

Weight management interventions in adults with intellectual disabilities and obesity: a systematic review of the evidence

o evaluate the clinical effectiveness of weight management interventions in adults with intellectual disabilities (ID) and obesity using recommendations from current clinical guidelines for the first line management of obesity in adults. Full papers on lifestyle modification interventions published between 1982 to 2011 were sought by searching the Medline, Embase, PsycINFO and CINAHL databases. Studies were evaluated based on 1) intervention components, 2) methodology, 3) attrition rate 4) reported weight loss and 5) duration of follow up. Twenty two studies met the inclusion criteria. The interventions were classified according to inclusion of the following components: behaviour change alone, behaviour change plus physical activity, dietary advice or physical activity alone, dietary plus physical activity advice and multi-component (all three components). The majority of the studies had the same methodological limitations: no sample size justification, small heterogeneous samples, no information on randomisation methodologies. Eight studies were classified as multi-component interventions, of which one study used a 600 kilocalorie (2510 kilojoule) daily energy deficit diet. Study durations were mostly below the duration recommended in clinical guidelines and varied widely. No study included an exercise program promoting 225–300 minutes or more of moderate intensity physical activity per week but the majority of the studies used the same behaviour change techniques. Three studies reported clinically significant weight loss (≥ 5%) at six months post intervention. Current data indicate weight management interventions in those with ID differ from recommended practice and further studies to examine the effectiveness of multi-component weight management interventions for adults with ID and obesity are justified

Web 2.0 systems supporting childhood chronic disease management: A pattern language representation of a general architecture

<p>Abstract</p> <p>Background</p> <p>Chronic disease management is a global health concern. By the time they reach adolescence, 10–15% of all children live with a chronic disease. The role of educational interventions in facilitating adaptation to chronic disease is receiving growing recognition, and current care policies advocate greater involvement of patients in self-care. Web 2.0 is an umbrella term for new collaborative Internet services characterized by user participation in developing and managing content. Key elements include Really Simple Syndication (RSS) to rapidly disseminate awareness of new information; weblogs (blogs) to describe new trends, wikis to share knowledge, and podcasts to make information available on personal media players. This study addresses the potential to develop Web 2.0 services for young persons with a chronic disease. It is acknowledged that the management of childhood chronic disease is based on interplay between initiatives and resources on the part of patients, relatives, and health care professionals, and where the balance shifts over time to the patients and their families.</p> <p>Methods</p> <p>Participatory action research was used to stepwise define a design specification in the form of a pattern language. Support for children diagnosed with diabetes Type 1 was used as the example area. Each individual design pattern was determined graphically using card sorting methods, and textually in the form <it>Title, Context, Problem, Solution, Examples and References</it>. <it>Application references </it>were included at the lowest level in the graphical overview in the pattern language but not specified in detail in the textual descriptions.</p> <p>Results</p> <p>The design patterns are divided into functional and non-functional design elements, and formulated at the levels of organizational, system, and application design. The design elements specify access to materials for development of the competences needed for chronic disease management in specific community settings, endorsement of self-learning through online peer-to-peer communication, and systematic accreditation and evaluation of materials and processes.</p> <p>Conclusion</p> <p>The use of design patterns allows representing the core design elements of a Web 2.0 system upon which an 'ecological' development of content respecting these constraints can be built. Future research should include evaluations of Web 2.0 systems implemented according to the architecture in practice settings.</p

The Making of Racial and Ethnic Categories: Official Statistics Reconsidered

One of the most striking features of the end of the twentieth century was the resurgence of the ethnic question in public debates, both in developing and in developed countries. Between conflicts and wars interpreted from an ethnic perspective (the Balkans and central Africa), nationalist struggles (the Basque country, Quebec and Belgium), and demands for recognition and political representation by new ethnic minorities resulting from immigration, every country is currently affected by what is commonly known as cultural pluralism (Hobsbawm 1993; Dieckhoff 2000; Faist 2009; Simon and Piché 2013). This ‘ethnic renewal’, to coin the expression used to qualify the growing interest for ethnic diversity in the 1960s in the US, is not only driven by a sort of obsession for cultural differences as an explanation for all kinds of social and political phenomenon. It derives from different legacies: from the increasing diversity of the population of countries that have undergone large immigration flows to the long lasting cohabitation of national minorities within modern Nation states, from the history of slavery to the post-colonial era. This resurgence or extension of the salience of ethnicity in most of the societies around the world can be found not only in public discourses, policy-making, scientific literature and popular representations, but also in the pivotal realm of statistics. Indeed, at the turn of century, an increasing number of countries are processing routinely data on ethnicity or race of their population. This is precisely what this book is about: ethnic and racial classifications in official statistics, as a reflection of the representations of population and an interpretation of social dynamics through different lenses