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Importance: Maternal smoking during pregnancy adversely affects offspring lung development, with lifelong decreases in pulmonary function and increased asthma risk. In a primate model, vitamin C blocked some of the in-utero effects of nicotine on lung development and offspring pulmonary function.Objective: To determine if newborns of pregnant smokers randomized to receive daily vitamin C would have improved results of pulmonary function tests (PFTs) and decreased wheezing compared with those randomized to placebo.Design, Setting, and Participants: Randomized, double-blind trial conducted in 3 sites in the Pacific Northwest between March 2007 and January 2011. One hundred fifty-nine newborns of randomized pregnant smokers (76 vitamin C treated and 83 placebo treated) and 76 newborns of pregnant nonsmokers were studied with newborn PFTs. Follow-up assessment including wheezing was assessed through age 1 year, and PFTs were performed at age 1 year.Interventions: Pregnant women were randomized to receive vitamin C (500 mg/d) (n = 89) or placebo (n = 90).Main Outcomes and Measures: The primary outcome was measurement of newborn pulmonary function (ratio of the time to peak tidal expiratory flow to expiratory time [TPTEF:TE] and passive respiratory compliance per kilogram [Crs/kg]) within 72 hours of age. Secondary outcomes included incidence of wheezing through age 1 year and PFT results at age 1 year. A subgroup of pregnant smokers and nonsmokers had genotyping performed.Results: Newborns of women randomized to vitamin C (n = 76), compared with those randomized to placebo (n = 83), had improved pulmonary function as measured by TPTEF:TE (0.383 vs 0.345 [adjusted 95% CI for difference, 0.011-0.062]; P = .006) and Crs/kg (1.32 vs 1.20 mL/cm H2O/kg [95% CI, 0.02-0.20]; P = .01). Offspring of women randomized to vitamin C had significantly decreased wheezing through age 1 year (15/70 [21%] vs 31/77 [40%]; relative risk, 0.56 [95% CI, 0.33-0.95]; P = .03). There were no significant differences in the 1-year PFT results between the vitamin C and placebo groups. The effect of maternal smoking on newborn lung function was associated with maternal genotype for the α5 nicotinic receptor (rs16969968) (P < .001 for interaction).Conclusions and Relevance: Supplemental vitamin C taken by pregnant smokers improved newborn PFT results and decreased wheezing through 1 year in the offspring. Vitamin C in pregnant smokers may be an inexpensive and simple approach to decrease the effects of smoking in pregnancy on newborn pulmonary function and respiratory morbidities.Trial Registration: clinicaltrials.gov Identifier: NCT00632476. [ABSTRACT FROM AUTHOR]

Background/context Systematic evidence reviews (SERs) identify knowledge gaps in the literature, a logical starting place for prioritizing future research. Varied methods have been used to elicit diverse stakeholders' input in such prioritization. Objective To pilot a simple, easily replicable process for simultaneously soliciting consumer, clinician and researcher input in the identification of research priorities, based on the results of the 2009 SER on screening adults for depression in primary care. Methods We recruited 20 clinicians, clinic staff, researchers and patient advocates to participate in a half-day event in October 2009. We presented SER research methods and the results of the 2009 SER. Participants took part in focus groups, organized by profession; broad themes from these groups were then prioritized in a formal exercise. The focus group content was also subsequently analysed for specific themes. Results Focus group themes generally reacted to the evidence presented; few were articulated as research questions. Themes included the need for resources to respond to positive depression screens, the impact of depression screening on delivery systems, concerns that screening tools do not address comorbid or situational causes of depression and a perceived 'disconnect' between screening and treatment. The two highest-priority themes were the system effects of screening for depression and whether depression screening effectively leads to improved treatment. Conclusion We successfully piloted a simple, half-day, easily replicable multi-stakeholder engagement process based on the results of a recent SER. We recommend a number of potential improvements in future endeavours to replicate this process. [ABSTRACT FROM AUTHOR]

BACKGROUND: The current study was performed to determine, in rural settings, the relation between the type and status of insurance coverage and being up-to-date for breast, cervical, and colorectal cancer screening. METHODS: Four primary care practices in 2 rural Oregon communities participated. Medical chart reviews that were conducted between October 2008 and August 2009 assessed insurance coverage and up-to-date status for breast, cervical, and colorectal cancer screening. Inclusion criteria involved having at least 1 health care visit within the past 5 years and being aged ≥ 55 years. RESULTS: The majority of patients were women aged 55 years to 70 years, employed or retired, and who had private health insurance and an average of 2.5 comorbid conditions. The overall percentage of eligible women who were up-to-date for cervical cancer screening was 30%; approximately 27% of women were up-to-date for clinical breast examination, 37% were up-to-date for mammography, and 19% were up-to-date for both mammography and clinical breast examination. Approximately 38% of men and 35% of women were up-to-date for colorectal cancer screening using any test at appropriate screening intervals. In general, having any insurance versus being uninsured was associated with undergoing cancer screening. For each type of screening, patients who had at least 1 health maintenance visit were significantly more likely to be up-to-date compared with those with no health maintenance visits. A significant interaction was found between having health maintenance visits, having any health insurance, and being up-to-date for cancer screening tests. CONCLUSIONS: Overall, the percentage of patients who were up-to-date for any cancer screening, especially cervical cancer screening, was found to be very low in rural Oregon. Patients with some form of health insurance were more likely to have had a health maintenance visit within the previous 2 years and to be up-to-date for breast, cervical, and/or colorectal cancer screening. Cancer 2012. © 2012 American Cancer Society. [ABSTRACT FROM AUTHOR]

Hypothesis: Screening for esophageal adenocarcinoma has focused on identifying Barrett esophagus (BE) in patientswithsevere, long-standing symptoms of gastroesophageal reflux disease(GERD). Unfortunately, 95% of patients who develop esophageal adenocarcinoma are unaware of the presence of BE before their cancer diagnosis, which meansthey neverhadbeen selected for screening.Onepossible explanation is that no correlation exists between the severity ofGERDsymptoms and cancer risk. Wehypothesize that severe GERD symptoms are not associated with an increase in the prevalence of BE, dysplasia, or cancer in patients undergoing primary endoscopic screening. Design: Cross-sectional study. Setting: University hospital. Patients: A total of 769 patients with GERD. Interventions: Primary screening endoscopy performed from November 1, 2004, through June 7, 2007. Main Outcomes Measures: Symptom severity, proton pump inhibitor therapy, and esophageal adenocarcinogenesis (ie, BE, dysplasia, or cancer). Results: Endoscopy revealed adenocarcinogenesis in 122 patients. An increasing number of severe GERD symptoms correlated positively with endoscopic findings of esophagitis (odds ratio, 1.05; 95% confidence interval, 1.01-1.09). Conversely, an increasing number of severe GERD symptoms were associated with decreased odds of adenocarcinogenesis (odds ratio, 0.94; 95% confidence interval, 0.89-0.98). Patients taking proton pump inhibitors were 61.3% and 81.5% more likely to have adenocarcinogenesis if they reported no severe typical or atypical GERD symptoms, respectively, compared with patients taking proton pump inhibitors, who reported that all symptoms were severe. Conclusions: Medically treated patients with mild or absent GERD symptoms have significantly higher odds of adenocarcinogenesis compared with medically treated patients with severe GERD symptoms. This finding may explain the failure of the current screening paradigm in which the threshold for primary endoscopic examination is based on symptom severity. [ABSTRACT FROM AUTHOR]

Background: Public interest in complementary and alternative medicine (CAM) has grown over the past decade, accompanied by increased demand for evidence-based approaches to CAM practice. In order to define the role evidence-based decision making has in CAM practice, CAM professionals must have a full understanding of evidence-based medicine (EBM) concepts. Objective: This paper describes the design, implementation, and evaluation of a week-long intensive EBM short course for CAM faculty at a naturopathic and classical Chinese medicine institution. Intervention: This 20-hour course, entitled Principles of EBM for CAM Professionals, teaches participants how to access and appraise biomedical literature, apply it to their work, and teach these concepts to their students. Results: Results from precourse and postcourse evaluations suggest that, in a small group of participants, there were significant changes in EBM practice attitudes, self-appraised skills, and objectively assessed skills as a result of this course. Participants indicated they were committed to increasing their use of EBM in practice, enhancing EBM skills, using EBM in teaching, and working to change the culture at their institution to support use of EBM. At six months, 80% of participants had fully or partially followed through on their commitment to change plans. [ABSTRACT FROM AUTHOR]

Background: The relationship between diabetes, GERD symptoms and acid-related mucosal damage has not been well studied.Aims: To better quantify risk of acid-related mucosal damage among patients with and without diabetes.Methods: A prospective study using 10 sites from the Clinical Outcomes Research Initiative (CORI) National Endoscopy Database surveyed patients undergoing EGD by telephone within 30 days on medical history, symptoms and demographics. Varices and feeding tube indications were excluded. Acid-related damage was defined as any of these findings recorded in CORI: Barrett's esophagus; esophageal inflammation (unless non-acid-related etiology); healed ulcer, duodenal, gastric or esophageal ulcer; stricture; and mucosal abnormality with erosion or ulcer.Results: Of 1,569 patients, 16% had diabetes, 95% being type 2. Diabetic patients were significantly more likely to be male, older and have a higher body mass index, and less likely to report frequent heartburn and non-steroidal anti-inflammatory drug use. No significant differences were found in acid reflux and proton pump inhibitor (PPI) use between groups. In unadjusted analyses, diabetic patients had a similar risk for acid-related damage than non-diabetic patients (OR 1.09; 95% CI: 0.83, 1.42) which persisted after adjusting for gender, age, acid reflux, acid indication and PPI use (OR 1.04; 95% CI: 0.79, 1.39).Conclusions: No difference in risk of acid-related mucosal damage was found, even after adjustment for potential confounders. Our data do not support the need for a lower threshold to perform endoscopy in diabetic patients. [ABSTRACT FROM AUTHOR]

The article presents a study which investigates association of chronic opioid therapy (COT) for chronic noncancer pain (CNCP) and receipt of preventive services. The study made use of the medical records of 704, 000 patients to compare the receipt of four preventive services in patients of COT for CNCP and non-COT patients. Results indicate that patients who use COT for CNCP have lower relative risk (RR) of receipt of screening for cervical cancer compared to patients not using COT.

Background & Aims: The risk of serious complications after colonoscopy has important implications for the overall benefits of colorectal cancer screening programs. We evaluated the incidence of serious complications within 30 days after screening or surveillance colonoscopies in diverse clinical settings and sought to identify potential risk factors for complications. Methods: Patients age 40 and over undergoing colonoscopy for screening, surveillance, or evaluation based an abnormal result from another screening test were enrolled through the National Endoscopic Database (CORI). Patients completed a standardized telephone interview approximately 7 and 30 days after their colonoscopy. We estimated the incidence of serious complications within 30 days of colonoscopy and identified risk factors associated with complications using logistic regression analyses. Results: We enrolled 21,375 patients. Gastrointestinal bleeding requiring hospitalization occurred in 34 patients (incidence 1.59/1000 exams; 95% confidence interval [CI], 1.10–2.22). Perforations occurred in 4 patients (0.19/1000 exams; 95% CI, 0.05–0.48), diverticulitis requiring hospitalization in 5 patients (0.23/1000 exams; 95% CI, 0.08–0.54), and postpolypectomy syndrome in 2 patients (0.09/1000 exams; 95% CI, 0.02–0.30). The overall incidence of complications directly related to colonoscopy was 2.01 per 1000 exams (95% CI, 1.46–2.71). Two of the 4 perforations occurred without biopsy or polypectomy. The risk of complications increased with preprocedure warfarin use and performance of polypectomy with cautery. Conclusions: Complications after screening or surveillance colonoscopy are uncommon. Risk factors for complications include warfarin use and polypectomy with cautery. [Copyright &y& Elsevier]

Background: To improve colonoscopy quality, reports must include key quality indicators that can be monitored. Objective: To determine the quality of colonoscopy reports in diverse practice settings. Setting: The consortium of the Clinical Outcomes Research Initiative, which includes 73 U.S. gastroenterology practice sites that use a structured computerized endoscopy report generator, which includes fields for specific quality indicators. Design: Prospective data collection from 2004 to 2006. Main Outcomes Measurements: Reports were queried to determine if specific quality indicators were recorded. Specific end points, including quality of bowel preparation, cecal intubation rate, and detection of polyp(s) >9 mm in screening examinations were compared for 53 practices with more than 100 colonoscopy procedures per year. Results: Of the 438,521 reports received during the study period, 13.9% did not include bowel-preparation quality and 10.1% did not include comorbidity classification. The overall cecal intubation rate was 96.3%, but cecal landmarks were not recorded in 14% of the reports. Missing polyp descriptors included polyp size (4.9%) and morphology (14.7%). Reporting interventions for adverse events during the procedure varied from 0% to 6.5%. Among average-risk patients who received screening examinations, the detection rate of polyps >9 mm, adjusted for age, sex, and race, was between 4% and 10% in 81% of practices. Limitation: Bias toward high rates of reporting because of the standard use of a computerized report generator. Conclusions: There is significant variation in the quality of colonoscopy reports across diverse practices, despite the use of a computerized report generator. Measurement of quality indicators in clinical practice can identify areas for quality improvement. [Copyright &y& Elsevier]