A system for rating the stability and strength of medical evidence

BACKGROUND: Methods for describing one's confidence in the available evidence are useful for end-users of evidence reviews. Analysts inevitably make judgments about the quality, quantity consistency, robustness, and magnitude of effects observed in the studies identified. The subjectivity of these judgments in several areas underscores the need for transparency in judgments. DISCUSSION: This paper introduces a new system for rating medical evidence. The system requires explicit judgments and provides explicit rules for balancing these judgments. Unlike other systems for rating the strength of evidence, our system draws a distinction between two types of conclusions: quantitative and qualitative. A quantitative conclusion addresses the question, "How well does it work?", whereas a qualitative conclusion addresses the question, "Does it work?" In our system, quantitative conclusions are tied to stability ratings, and qualitative conclusions are tied to strength ratings. Our system emphasizes extensive a priori criteria for judgments to reduce the potential for bias. Further, the system makes explicit the impact of heterogeneity testing, meta-analysis, and sensitivity analyses on evidence ratings. This article provides details of our system, including graphical depictions of how the numerous judgments that an analyst makes can be combined. We also describe two worked examples of how the system can be applied to both interventional and diagnostic technologies. SUMMARY: Although explicit judgments and formal combination rules are two important steps on the path to a comprehensive system for rating medical evidence, many additional steps must also be taken. Foremost among these are the distinction between quantitative and qualitative conclusions, an extensive set of a priori criteria for making judgments, and the direct impact of analytic results on evidence ratings. These attributes form the basis for a logically consistent system that can improve the usefulness of evidence reviews

Young volcanism and related hydrothermal activity at 5°S on the slow-spreading southern Mid-Atlantic Ridge

The effect of volcanic activity on submarine hydrothermal systems has been well documented along fast- and intermediate-spreading centers but not from slow-spreading ridges. Indeed, volcanic eruptions are expected to be rare on slow-spreading axes. Here we report the presence of hydrothermal venting associated with extremely fresh lava flows at an elevated, apparently magmatically robust segment center on the slow-spreading southern Mid-Atlantic Ridge near 5°S. Three high-temperature vent fields have been recognized so far over a strike length of less than 2 km with two fields venting phase-separated, vapor-type fluids. Exit temperatures at one of the fields reach up to 407°C, at conditions of the critical point of seawater, the highest temperatures ever recorded from the seafloor. Fluid and vent field characteristics show a large variability between the vent fields, a variation that is not expected within such a limited area. We conclude from mineralogical investigations of hydrothermal precipitates that vent-fluid compositions have evolved recently from relatively oxidizing to more reducing conditions, a shift that could also be related to renewed magmatic activity in the area. Current high exit temperatures, reducing conditions, low silica contents, and high hydrogen contents in the fluids of two vent sites are consistent with a shallow magmatic source, probably related to a young volcanic eruption event nearby, in which basaltic magma is actively crystallizing. This is the first reported evidence for direct magmatic-hydrothermal interaction on a slow-spreading mid-ocean ridge

Special Article: 2018 American College of Rheumatology/National Psoriasis Foundation Guideline for the Treatment of Psoriatic Arthritis

OBJECTIVE: To develop an evidence-based guideline for the pharmacologic and nonpharmacologic treatment of psoriatic arthritis (PsA), as a collaboration between the American College of Rheumatology (ACR) and the National Psoriasis Foundation (NPF). METHODS: We identified critical outcomes in PsA and clinically relevant PICO (population/intervention/comparator/outcomes) questions. A Literature Review Team performed a systematic literature review to summarize evidence supporting the benefits and harms of available pharmacologic and nonpharmacologic therapies for PsA. GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology was used to rate the quality of the evidence. A voting panel, including rheumatologists, dermatologists, other health professionals, and patients, achieved consensus on the direction and the strength of the recommendations. RESULTS: The guideline covers the management of active PsA in patients who are treatment-naive and those who continue to have active PsA despite treatment, and addresses the use of oral small molecules, tumor necrosis factor inhibitors, interleukin-12/23 inhibitors (IL-12/23i), IL-17 inhibitors, CTLA4-Ig (abatacept), and a JAK inhibitor (tofacitinib). We also developed recommendations for psoriatic spondylitis, predominant enthesitis, and treatment in the presence of concomitant inflammatory bowel disease, diabetes, or serious infections. We formulated recommendations for a treat-to-target strategy, vaccinations, and nonpharmacologic therapies. Six percent of the recommendations were strong and 94% conditional, indicating the importance of active discussion between the health care provider and the patient to choose the optimal treatment. CONCLUSION: The 2018 ACR/NPF PsA guideline serves as a tool for health care providers and patients in the selection of appropriate therapy in common clinical scenarios. Best treatment decisions consider each individual patient situation. The guideline is not meant to be proscriptive and should not be used to limit treatment options for patients with PsA

The evolution of the image of China in the United States during the cold war

This article describes the evolution of the image of China in the United States (US) during the Cold War. Aware that China-US bilateral relations have been influenced by periods of conflict and animosity, harmony and détente, the article argues that the image of China has always been embedded in a network of events - birth of the PRC (People's Republic of China [PRC], Korean War, Sino-Soviet alliance) that prevented American public opinion from developing an objective and unbiased picture of the PRC. Since 1950s, China has always been linked to the idea of the 'Yellow Peril'. Moreover, the lack of a direct contact between China and America further thwarted the opportunity of shaping a fair picture of the PRC. Although recognising that during the Cold War American political parties played a significant role in conveying a negative image of China, this article shows how media helped in strengthening Chinese stereotypes among the American public. Analysing all articles published by Time, National Geographic and Readers' Digest from 1949 to 1972, the article highlights both similarities and differences of the way in which these magazines introduced China to their readers. © Sage Publication 2009.link_to_subscribed_fulltex

2021 American College of Rheumatology Guideline for the Treatment of Juvenile Idiopathic Arthritis: Therapeutic Approaches for Oligoarthritis, Temporomandibular Joint Arthritis, and Systemic Juvenile Idiopathic Arthritis

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/172047/1/art42037.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/172047/2/art42037-sup-0001-Disclosureform.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/172047/3/art42037_am.pd

The top patient safety strategies that can be encouraged for adoption now

Progress in patient safety improvement has been hindered by a lack of high-quality research on error prevention, poor understanding of how context influences safety strategies, and insufficient information on how best to implement evidence-based safety strategies. The Agency for Healthcare Research and Quality funded a multi-institutional effort to address these challenges, which culminated in the release of the Making Health Care Safer II report. Detailing methodology that the report's authors used to systematically review the evidence on effectiveness, context, and implementation for 41 key safety strategies, this commentary presents 10 strategies considered ready for widespread implementation. These strategies—including checklists to prevent certain health care–associated infections and surgical complications, bundled interventions to reduce falls and pressure ulcers, and interventions to decrease medication errors and improve hand hygiene—are all considered to have strong evidence of effectiveness, minimal potential for adverse consequences, and be reasonably easy to implement. This commentary is part of a special patient safety supplement in the Annals of Internal Medicine