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Background Investigations of age effects on youth anxiety outcomes in randomized trials (RCTs) of cognitive behavior therapy (CBT) have failed to yield a clear result due to inadequate statistical power and methodologic weaknesses. We conducted an individual patient data metaanalysis to address this gap. Question Does age moderate CBT effect size, measured by a clinically and statistically significant interaction between age and CBT exposure? Methods All English language RCTs of CBT for anxiety in 6-19 year olds were identified using systematic review methods. Investigators of eligible trials were invited to submit their individual patient data. The anxiety disorder interview schedule (ADIS) primary diagnosis severity score was the primary outcome. Age effects were investigated using multilevel modeling to account for study level data clustering and random effects. Results Data from 17 of 23 eligible trials were obtained (74%); 16 studies and 1,171 (78%) cases were available for the analysis. No interaction between age and CBT exposure was found in a model containing age, sex, ADIS baseline severity score, and comorbid depression diagnosis (power ≥ 80%). Sensitivity analyses, including modeling age as both a categorical and continuous variable, revealed this result was robust. Conclusions Adolescents who receive CBT in efficacy research studies show benefits comparable to younger children. However, CBT protocol modifications routinely carried out by expert trial therapists may explain these findings. Adolescent CBT protocols are needed to facilitate the transportability of efficacy research effects to usual care settings where therapists may have less opportunity for CBT training and expertise development.

Objective To investigate the credibility of authors' claims of subgroup effects using a representative sample of recently published randomised controlled trials. Design Systematic review. Data source Core clinical journals, as defined by the National Library of Medicine, in Medline. Study selection Randomised controlled trials published in 2007. Using prespecified criteria, teams of trained reviewers independently judged whether authors claimed subgroup effects and the strength of their claims. Reviewers assessed each of these claims against 10 predefined criteria, developed through a search of existing criteria and a consensus process. Results Of 207 randomised controlled trials reporting subgroup analyses, 64 (31%) made claims for the primary outcome. Of those, 20 were strong claims and 28 claims of a likely effect. Authors included subgroup variables measured at baseline in 60 (94%) trials, used subgroup variable as a stratification factor at randomisation in 13 (20%), clearly prespecified their hypotheses in 26 (41%), correctly prespecified direction in 4 (6%), tested a small number of hypotheses in 28 (44%), carried out a test of interaction that proved statistically significant in 6 (9%), documented replication of a subgroup effect with previous related studies in 21 (33%), identified consistency of a subgroup effect across related outcomes in 19 (30%), and provided a compelling indirect evidence for the effect in 14 (22%). In the 19 trials making more than one claim, only one (5%) checked the independence of the interaction. Of the 64 claims, 54 (84%) met four or fewer of the 10 criteria. For strong claims, more than 50% failed each of the individual criteria, and only three (15%) met more than five criteria. Conclusion Authors often claim subgroup effects in their trial report. However, the credibility of subgroup effects, even when claims are strong, is usually low. Users of the information should treat claims that fail to meet most criteria with scepticism. Trial researchers should report the conduct of subgroup analyses and provide sufficient evidence when claiming a subgroup effect or suggesting a possible effect.

Background Survivors of ARDS report depressive symptoms and memory complaints, the prevalence of which after 5 years is unknown. Methods We administered instruments assessing symptoms of depression (Beck Depression Inventory II [BDI-II]) and memory complaints (Memory Assessment Clinics Self-Rating Scale [MAC-S]) to 64 survivors of ARDS from four university-affiliated ICUs 5 years after ICU discharge. We compared BDI-II scores to quality of life (Medical Outcomes Study 36-Item Short Form [SF-36]) mental health domains (role emotional, mental health, mental component summary), compared BDI-II and MAC-S scores to earlier scores (median, 22 months postdischarge), and examined return to work. Results Forty-three (67.2%), 46 (71.9%), and 38 (59.4%) patients fully completed the BDI-II, MAC-S ability subscale, and MAC-S frequency of occurrence subscale, respectively. Responders were young (median, 48 years; first-third quartile [Q1-Q3], 39-61 years) with high illness severity. The median BDI-II score was 10 (Q1-Q3, 3-18); eight of 43 (18.6%) had moderate to severe depressive symptoms compared with 14 of 43 (32.6%) earlier ( P = .15, n = 38 with paired data). Median MAC-S ability and MAC-S frequency scores were 81 (Q1-Q3, 57-92) and 91.5 (Q1-Q3, 76-105), respectively, similar to earlier scores ( P = .67 and P = .64, respectively); 0% to 4.3% scored > 2 SDs below population norms. Higher BDI-II score was predicted by higher earlier BDI-II score, slower recovery of organ function, and longer duration of mechanical ventilation and ICU stay. Higher MAC-S score was predicted by higher earlier MAC-S score. SF-36 mental health domain scores were very stable ( P = .57-.83). BDI-II and SF-36 mental health domains were negatively correlated (Spearman coefficient, −0.50 to −0.82). Most patients returned to work regardless of depressive symptoms (minimal to mild, 31 of 35 [88.6%]; moderate to severe, five of eight [62.5%]; P = .12). Conclusions Compared with ∼ 2 years postdischarge from the ICU, depressive symptoms and memory complaints were similar at 5 years. Mental health domains of the SF-36 may not be sensitive to small changes in mood symptoms.

Objective: People hospitalized for depression are often discharged before the acute phase of their illness has resolved and need timely care transitions to prevent relapse. We examined 30-day postdischarge service use for Ontarians, aged 15 years or older, who were hospitalized for depression. We focused on a pattern consistent with guideline and policy directions: higher rates of physician visits, postdischarge, combined with lower rates of emergency department (ED) admissions or rehospitalization. Methods: Administrative data for the fiscal year of 2005 were used to identify hospitalizations for depression and subsequent physician visits, ED admissions, or readmissions for depression within 30 days, postdischarge. Sex, age, income, and geographic location were examined along with the relation between health care resources (beds, EDs, and physicians) and postdischarge service use. Results: Sixty-three percent of patients discharged for depression were followed, within 30 days, by a physician visit for depression. Twenty-five percent were either rehospitalized or visited an ED. Women and people from urban or high income areas were more likely to have postdischarge physician visits. Readmissions and ED visits were correlated with number of EDs, but postdischarge physician visits were not related to the number of general practitioners, family physicians, and psychiatrists in the local area. Conclusion: One-third of Ontarians hospitalized for depression did not receive recommended follow-up outpatient care within 30 days of discharge and one-quarter received follow-up through ED visits or readmissions, highlighting the need to improve coordination and integration across care settings for these patients. There are tested transitional and outpatient models that improve quality and outcomes of depression care that merit serious consideration.

Gender disparities in mental health highlight the need to include gender equity measures when planning, implementing, and evaluating mental health programs at national, state or provincial, and municipal levels. This study aimed to identify, select, and assess the feasibility of comparing gender-sensitive mental health indicators in a low- (Peru), middle- (Colombia), and high- (Canada) income country.The indicators were selected by a multidisciplinary group of experts who used criteria and a framework proposed by the World Health Organization. Data from national, population-based databases from each country were used to measure the indicators.Seven indicators (12-month prevalence of the following: depression, psychological distress, generalized anxiety disorder, suicide attempts, alcohol dependence, mental health service use, and psychological impairment) were feasible for measurement in at least two countries. Only five indicators were comparable between two countries, and only one was comparable among all countries (suicide attempts). The indicators that showed the greatest inequities between men and women were depression, anxiety, suicide attempts, use of mental health services, and alcohol dependence. Female-to-male ratios for prevalence of mental illness ranged from .1 to 2.3, and ratios for service use ranged from 1.3 to 1.9. Significant trends were found when the indicators were considered by age, education, marital status, and income.Some of these indicators can be used to identify populations most vulnerable to gender inequities in mental health. The results from this study may provide useful information to program planners who aim to implement, improve, and monitor national mental health strategies that reduce gender inequities under different national conditions.

Objective: While everyone—including front-line clinicians—should strive to prevent the maltreatment and other severe stresses experienced by many children and adults in everyday life, psychiatrists and other health professionals also need to consider how best to support, throughout the lifespan, those people affected by severe adversity. The first step in achieving this is a clear understanding of the definitions and concepts in the rapidly growing study of resilience. Our paper reviews the definitions of resilience and the range of factors understood as contributing to it, and considers some of the implications for clinical care and public health. Method: This narrative review took a major Canadian report published in 2006 as its starting point. The databases, MEDLINE and PsycINFO, were searched for new relevant citations from 2006 up to July 2010 to identify key papers considering the definitions of resilience and related concepts. Results: Definitions have evolved over time but fundamentally resilience is understood as referring to positive adaptation, or the ability to maintain or regain mental health, despite experiencing adversity. The personal, biological, and environmental or systemic sources of resilience and their interaction are considered. An interactive model of resilience illustrates the factors that enhance or reduce homeostasis or resilience. Conclusions: The 2 key concepts for clinical and public health work are: the dynamic nature of resilience throughout the lifespan; and the interaction of resilience in different ways with major domains of life function, including intimate relationships and attachments.

Background: As gender is known to be a major determinant of health, monitoring gender equity in health systems remains a vital public health priority. Focusing on a low-income (Peru), middle-income (Colombia), and high-income (Canada) country in the Americas, this study aimed to (1) identify and select gender-sensitive health indicators and (2) assess the feasibility of measuring and comparing gender-sensitive health indicators among countries. Methods: Gender-sensitive health indicators were selected by a multidisciplinary group of experts from each country. The most recent gender-sensitive health measures corresponding to selected indicators were identified through electronic databases (CINAHL, PsycINFO, MEDLINE, Embase, LILACS, LIPECS, Latindex, and BIREME) and expert consultation. Data from population-based studies were analyzed when indicator information was unavailable from reports. Results: Twelve of the 17 selected gender-sensitive health indicators were feasible to measure in at least two countries, and 9 of these were comparable among all countries. Indicators that were available were not stratified or adjusted by age, education, marital status, or wealth. The largest between-country difference was maternal mortality, and the largest gender inequity was mortality from homicides. Conclusions: This study shows that gender inequities in health exist in all countries, regardless of income level. Economic development seemed to confer advantages in the availability of such indicators; however, this finding was not consistent and needs to be further explored. Future initiatives should include identifying health system factors and risk factors associated with disparities as well as assessing the cost-effectiveness of including the routine monitoring of gender inequities in health.

Background Depression after stroke occurs in 33% of individuals. It is grossly underdiagnosed and untreated. Objective The authors studied sex differences in the prevalence of post-stroke depression (PSD), which have not been adequately studied, and may have important implications for clinicians. Method The authors performed a systematic review of five databases of all observational studies that stratified data by sex, measuring the prevalence of PSD. Results Fiftysix publications, including 47 primary studies between 1982 and 2006, met eligibility criteria and were included in the review. A total of 75,131 subjects comprised these studies, with 11,910 women and 62,899 men. Results The prevalence of depression among women was higher in 35 studies. Moreover, the prevalence was generally higher among inpatient populations (both in acute-care and rehabilitation facilities) than in community-dwelling subjects. Conclusions PSD is highly prevalent in both sexes, but appears to be slightly more common among women than men. Untreated depression after stroke can lead to a reduced quality of life, poorer prognosis, and increased mortality. All stroke patients should be routinely screened for depression, and further research is needed to determine whether there are sex-specific differences in response to treatment.

Survivors of ARDS have well documented physical limitations, but psychological effects are less clear. We determined the prevalence of self-reported depression and memory dysfunction in ARDS survivors.Six to 48 (median 22) months after ICU discharge, we administered instruments assessing depression symptoms (Beck Depression Inventory-II [BDI-II]) and memory dysfunction (Memory Assessment Clinics Self-Rating Scale [MAC-S]) to 82 ARDS patients who were enrolled in a prospective cohort study in four university-affiliated ICUs.Sixty-one (74%), 64 (78%), and 61 (74%) patients fully completed the BDI-II, MAC-S (Ability subscale), and MAC-S (Frequency of Occurrence subscale) instruments. Responders (similar to nonresponders) were young (median 42 years, interquartile range [IQR] 35 to 56), with high admission illness severity and organ dysfunction. The median BDI-II score was 12 (IQR 5 to 25). Twenty-five (41%) patients reported moderate-severe depression symptoms and were less likely to return to work than those with minimal-mild symptoms (8/25 [32%] vs 25/36 [69%]; p = 0.005). Median MAC-S (Ability) and MAC-S (Frequency of Occurrence) scores were 76 (IQR 61 to 93) and 91 (IQR 77 to 102), respectively; 8%, 16%, and 20% scored2,1.5, and1 SD(s), respectively, below age-adjusted population norms for each subscale. BDI-II and MAC-S scores were negatively correlated (Spearman coefficient -0.58 and -0.50 for Ability and Frequency of Occurrence subscales, respectively; p0.0001). Univariable analyses showed no demographic or illness-severity predictors of BDI-II (including the Cognitive subscale) or MAC-S (both subscales); results were similar when restricted to patients whose primary language was English.ARDS survivors report a high prevalence of depression symptoms and a lower prevalence of memory dysfunction 6 to 48 months after ICU discharge. Depression symptoms may hinder the return to work, or patients may report these symptoms because of inability to re-enter the workforce.

Objectives To determine the relationship between the premortem and postmortem diagnosis in critically ill bone marrow transplantation patients Also, to evaluate the appropriateness of the reliance on clinical diagnosis for withdrawal of active treatment decision-making. Design Retrospective cohort study. Setting Two university-affiliated tertiary care medical surgical intensive care units. Patients Critically ill bone marrow transplantation patients who died in the intensive care unit between November 1, 1994, and June 30, 1999, and underwent postmortem examination. Intervention Review of medical records by two independent data extractors. Clinical diagnosis and cause of death in the intensive care unit were compared with the final autopsy report. Measurements and Main Results Premortem clinical diagnoses were classified according to the Goldman criteria and compared with postmortem findings. Twenty-eight autopsies were done. Ten of 28 (36%) patients had discrepancies uncovered on autopsy; only two discrepancies would have influenced patient management and none would have altered patient outcome. Twenty patients had their active treatment withdrawn and underwent postmortem examination. None of the discrepancies noted would have altered outcome in these patients. Conclusion In the bone marrow transplantation population, there is significant concordance between clinical diagnosis and postmortem findings. Reliance on clinical diagnosis may be valid for withdrawal of active treatment decision-making in these patients.

People who have experienced intimate partner violence (IPV) or child maltreatment (CM) are at risk of having lower resilience and adverse psychological outcomes. In keeping with the social and environmental factors that support resilience, there is a need to take a public health approach to its investigation and to identify existing initiatives in particular settings and populations that can guide its deliberate promotion.This narrative synthesis examines quantitative and qualitative studies of interventions with resilience-related outcomes in specified health and other settings. Clinical RCTs are excluded as beyond the scope of this review.Twenty studies were identified for review in several settings, consisting of 14 quantitative studies, 2 review studies, 2 qualitative studies and 2 mixed-methods studies. Three quantitative studies produced strong evidence to support: a home visitation program for at-risk mothers; a methadone program for women and a substance abuse program. This review reveals that few studies use specific resilience measures.The topic has been little studied despite high needs for public health interventions in countries of all types. Interventions and research studies that use specific resilience measures are likely to help measure and integrate what is currently a disparate area.The participation of people with IPV or CM history in program and research design and implementation is indicated to support advocacy, innovation and sustainable interventions. This is especially pertinent for interventions in LAMIC and indigenous settings where continuing programs are sorely needed.

Inhibition of phosphodiesterase (PDE) activity is beneficial in models of arthritis and airway inflammation. Here we assessed the ability of PDE inhibitors to modulate colitis by exposing mice to 4% (w/v) dextran sulfate sodium (DSS) drinking water for 5 days with or without rolipram, an inhibitor of PDE type 4, or the nonselective PDE inhibitor, pentoxifylline (both at 5 mg/kg, i.p., twice daily). Controls received saline, vehicle, or drug only. Colonic histology, myeloperoxidase (MPO) and tumor necrosis factor-alpha (TNF-alpha) levels, and epithelial ion transport (baseline and stimulated by electrical nerve stimulation, carbachol, and forskolin) were examined. DSS-treated mice displayed a variable diarrhea, significant histopathology in the mid-distal colon, elevated MPO activity, and reduced (50%) responses to all three pro-secretory stimuli. Treatment with rolipram, and to a lesser extent pentoxifylline, significantly reduced the severity of the colonic histopathology and MPO levels. Neither PDE inhibitor had any affect on the diminished ion transport events caused by DSS-induced colitis. However, although stimulated ion transport events were still reduced 3 days after DSS treatment, colonic segments from DSS + rolipram-treated mice displayed enhanced recovery in their secretory responsiveness, particularly to carbachol. These findings indicate that specific PDE4 inhibition can significantly reduce the tissue damage that accompanies colitis and enhance recovery of normal colonic function.

Objective: To compare methodological characteristics of randomized controlled trials (RCTs) published in higher vs. lower impact Core Clinical Journals. Study Design and Setting: We searched MEDLINE for RCTs published in 2007 in Core Clinical Journals. We randomly sampled 1,140 study reports in a 1:1 ratio in higher (five general medicine journals with the highest total citations in 2007) and lower impact journals. Results: Four hundred sixty-nine RCTs proved eligible: 219 in higher and 250 in lower impact journals. RCTs in higher vs. lower impact journals had larger sample sizes (median, 285 vs. 39), were more likely to receive industry funding (53% vs. 28%), declare concealment of allocation (66% vs. 36%), declare blinding of health care providers (53% vs. 41%) and outcome adjudicators (72% vs. 54%), report a patient-important primary outcome (69% vs. 50%), report subgroup analyses (64% vs. 26%), prespecify subgroup hypotheses (42% vs. 20%), and report a test for interaction (54% vs. 27%); P < 0.05 for all differences. Conclusion: RCTs published in higher impact journals were more likely to report methodological safeguards against bias and patient-important outcomes than those published in lower impact journals. However, sufficient limitations remain such that publication in a higher impact journal does not ensure low risk of bias. © 2013 Elsevier Inc. All rights reserved.

There have been few detailed, in-person interviews and examinations to obtain follow-up data on 5-year outcomes among survivors of the acute respiratory distress syndrome (ARDS).We evaluated 109 survivors of ARDS at 3, 6, and 12 months and at 2, 3, 4, and 5 years after discharge from the intensive care unit. At each visit, patients were interviewed and examined; underwent pulmonary-function tests, the 6-minute walk test, resting and exercise oximetry, chest imaging, and a quality-of-life evaluation; and reported their use of health care services.At 5 years, the median 6-minute walk distance was 436 m (76% of predicted distance) and the Physical Component Score on the Medical Outcomes Study 36-Item Short-Form Health Survey was 41 (mean norm score matched for age and sex, 50). With respect to this score, younger patients had a greater rate of recovery than older patients, but neither group returned to normal predicted levels of physical function at 5 years. Pulmonary function was normal to near-normal. A constellation of other physical and psychological problems developed or persisted in patients and family caregivers for up to 5 years. Patients with more coexisting illnesses incurred greater 5-year costs.Exercise limitation, physical and psychological sequelae, decreased physical quality of life, and increased costs and use of health care services are important legacies of severe lung injury.

Objective: Knowledge is lacking on the extent to which area-level characteristics contribute to variations observed in the use of mental health services. This study examined the influence of area- and individual-level characteristics on the use of mental health services. Methods: Data from a nationally representative, population-based, cross-sectional survey, the Canadian Community Health Survey-Mental Health and Well-Being, consisting of adults aged 15 years or older (n = 36 984), were linked to Canadian 2001 Census profiles according to health region boundaries (n = 97). Multilevel multivariable logistic regression modelling was used to: estimate variation in 12-month self-reported use of health services for mental health reasons between health regions; and, estimate the effects of individual- and area-level need, health resources, and sociodemographic factors on self-reported 12-month use of medical services for mental health reasons. Results: There was a 2.1% and 3.5% regional variation for general practitioner-family physician (GP-FP) and psychiatric health service use during 12 months, respectively. Most of the regional variation observed was explained by number of physicians per health region and regional and individual need factors. Adults who were middle-aged, had a post-secondary education, low-income, were separated, widowed, or divorced, and Canadian-born were significantly more likely to use GP-FP and psychiatry services for mental health reasons at the individual level, even after adjusting for area- and individual-level need factors. Conclusions: Most area-level variation was explained by the availability of health region resources and individual-level need factors. After accounting for need, numerous sociodemographic factors retained their association with use of mental health services. Additional efforts are needed at the area and individual level to reduce inequities through appropriate targeted care. Can J Psychiatry. 2010;55(1):9-20. Clinical Implications * Variations between health regions in use of health services for mental health reasons were accounted for mostly by physician supply and individual-level need factors. * After adjusting for area- and individual-level need, significant associations persisted between the sociodemographic characteristics of people and increased use of mental health services. Limitations * Perceived need for care, treatment preference and satisfaction, and actual use of health care services for mental health reasons were not examined. * The cross-sectional nature of this study does not allow us to estimate whether previous or present treatment with medical care was successful. * Severity of illness and variations in severity of mental health needs across health regions were not included in this analysis. Key Words: small area analysis, multilevel analysis, depression, health service use, need, equity Abbreviations used in this article CCHS 1.2 Canadian Community Health Survey - Mental Health and Weil-Being DSM Diagnostic and Statistical Manual of Mental Disorders GP-FP general practitioner-family physician WMH-CIDI World Mental Health version of the Composite International Diagnostic Interview Neighbourhood-level characteristics such as income inequality, unemployment, and immigrant concentration are known to exert area influences on health status and health service use after controlling for individual-level characteristics.1'2 This appears to be particularly true for people living in disadvantaged areas characterized by poverty, high economic inactivity, and social disorganization. "* The influence of area disadvantage on health status and health service use raises the possibility that living in certain areas may influence health service use independent of heath care need. This would violate the principle of equity in the provision and allocation of health services, defined as equal access to available care given for equal need. …

Gender inequities in health prevail in most countries despite ongoing attempts to eliminate them. Assessment of gender-sensitive health policies can be used to identify country specific progress as well as gaps and issues that need to be addressed to meet health equity goals. This study selected and measured the existence of gender-sensitive health policies in a low- (Peru), middle- (Colombia), and high (Canada)-income country in the Americas. Investigators selected 10 of 20 gender-sensitive health policy indicators and found eight to be feasible to measure in all three countries, although the wording and scope varied. The results from this study inform policy makers and program planners who aim to develop, improve, implement, and monitor national gender-sensitive health policies. Future studies should assess the implementation of policy indicators within countries and assess their performance in increasing gender equity.

We describe complementary and alternative medicine use (CAM) in 360 patients attending osteoporosis clinics. Of these patients, 57% were CAM users. Predictors of CAM use included lower mental quality of life, younger age and higher education. Less than half of CAM use was disclosed to physicians, despite potential adverse interactions. The prevalence of complementary and alternative medicine (CAM) use in osteoporosis clinics is not known. The objective of this study was to describe the pattern of CAM use in this population. We performed a cross-sectional study of 360 patients attending academic osteoporosis clinics in Toronto, Canada in 2001. Subjects completed a self-administered questionnaire on CAM use. Health-related quality of life (HQL) was measured with the Short-Form 36v2. Comparative statistics and logistic regression were performed to identify sociodemographic, HQL and clinical correlates of CAM use. More than 80% of participants were women, Caucasian and had at least a high school education. Of subjects, 57% used CAM in the previous year. Only 44% of CAM use was disclosed to a medical doctor. CAM users and non-users did not differ in clinical characteristics such as bone mineral density, level of comorbidity and fracture history. In univariate analysis, CAM users were less satisfied with conventional medicine. However, when we explored patient satisfaction, comorbidities and sociodemographic as predictors for CAM use, the multivariable analyses showed that lower mental HQL, younger age, and post-secondary education were the only significant predictors. We identified 35 cases in which the utilization of CAM supplements could possibly exacerbate existing medical conditions. Patients attending osteoporosis clinics frequently use CAM. Conceptually, the predictors of use identified in this study may fit into a socio-behavioral model that helps explain why people turn to CAM. Physicians may need to elicit a history of CAM use more vigilantly so as to better screen for possible adverse clinical interactions.

Little is known about the long-term outcomes and costs of survivors of acute respiratory distress syndrome (ARDS).To describe functional and quality of life outcomes, health care use, and costs of survivors of ARDS 2 yr after intensive care unit (ICU) discharge.We recruited a cohort of ARDS survivors from four academic tertiary care ICUs in Toronto, Canada, and prospectively monitored them from ICU admission to 2 yr after ICU discharge.Clinical and functional outcomes, health care use, and direct medical costs.Eighty-five percent of patients with ARDS discharged from the ICU survived to 2 yr; overall 2-yr mortality was 49%. At 2 yr, survivors continued to have exercise limitation although 65% had returned to work. There was no statistically significant improvement in health-related quality of life as measured by Short-Form General Health Survey between 1 and 2 yr, although there was a trend toward better physical role at 2 yr (p = 0.0586). Apart from emotional role and mental health, all other domains remained below that of the normal population. From ICU admission to 2 yr after ICU discharge, the largest portion of health care costs for a survivor of ARDS was the initial hospital stay, with ICU costs accounting for 76% of these costs. After the initial hospital stay, health care costs were related to hospital readmissions and inpatient rehabilitation.Survivors of ARDS continued to have functional impairment and compromised health-related quality of life 2 yr after discharge from the ICU. Health care use and costs after the initial hospitalization were driven by hospital readmissions and inpatient rehabilitation.

[Figure][1] Fig. 1: Recommendations of the Canadian Task Force on Preventive Health Care for the prevention of osteoporotic fractures in postmenopausal women. This algorithm excludes women with secondary osteoporosis (e.g., those who have hyperparathyroidism or are taking steroids). *World

As more patients survive the acute respiratory distress syndrome, an understanding of the long-term outcomes of this condition is needed.We evaluated 109 survivors of the acute respiratory distress syndrome 3, 6, and 12 months after discharge from the intensive care unit. At each visit, patients were interviewed and underwent a physical examination, pulmonary-function testing, a six-minute-walk test, and a quality-of-life evaluation.Patients who survived the acute respiratory distress syndrome were young (median age, 45 years) and severely ill (median Acute Physiology, Age, and Chronic Health Evaluation score, 23) and had a long stay in the intensive care unit (median, 25 days). Patients had lost 18 percent of their base-line body weight by the time they were discharged from the intensive care unit and stated that muscle weakness and fatigue were the reasons for their functional limitation. Lung volume and spirometric measurements were normal by 6 months, but carbon monoxide diffusion capacity remained low throughout the 12-month follow-up. No patients required supplemental oxygen at 12 months, but 6 percent of patients had arterial oxygen saturation values below 88 percent during exercise. The median score for the physical role domain of the Medical Outcomes Study 36-item Short-Form General Health Survey (a health-related quality-of-life measure) increased from 0 at 3 months to 25 at 12 months (score in the normal population, 84). The distance walked in six minutes increased from a median of 281 m at 3 months to 422 m at 12 months; all values were lower than predicted. The absence of systemic corticosteroid treatment, the absence of illness acquired during the intensive care unit stay, and rapid resolution of lung injury and multiorgan dysfunction were associated with better functional status during the one-year follow-up.Survivors of the acute respiratory distress syndrome have persistent functional disability one year after discharge from the intensive care unit. Most patients have extrapulmonary conditions, with muscle wasting and weakness being most prominent.

Objective To investigate the impact of industry funding on reporting of subgroup analyses in randomised controlled trials. Design Systematic review. Data sources Medline. Study selection Randomised controlled trials published in 118 core clinical journals (defined by the National Library of Medicine) in 2007. 1140 study reports in a 1:1 ratio by high (five general medicine journals with largest number of total citations in 2007) versus lower impact journals, were randomly sampled. Two reviewers, independently and in duplicate, used standardised, piloted forms to screen study reports for eligibility and to extract data. They also used explicit criteria to determine whether a randomised controlled trial reported subgroup analyses. Logistic regression was used to examine the association of prespecified study characteristics with reporting versus not reporting of subgroup analyses. Results 469 randomised controlled trials were included, of which 207 (44%) reported subgroup analyses. High impact journals (adjusted odds ratio 2.64, 95% confidence interval 1.62 to 4.33), non-surgical (versus surgical) trials (2.10, 1.26 to 3.50), and larger sample size (3.38, 1.64 to 6.99) were associated with more frequent reporting of subgroup analyses. The strength of association between trial funding and reporting of subgroups differed in trials with and without statistically significant primary outcomes (interaction P=0.02). In trials without statistically significant results for the primary outcome, industry funded trials were more likely to report subgroup analyses (2.29, 1.30 to 4.72) than non-industry funded trials. This was not true for trials with a statistically significant primary outcome (0.79, 0.46 to 1.36). Industry funded trials were associated with less frequent prespecification of subgroup hypotheses (31.3% v 38.0%, adjusted odds ratio 0.49, 0.26 to 0.94), and less use of the interaction test for analyses of subgroup effects (41.4% v 49.1%, 0.52, 0.28 to 0.97) than non-industry funded trials. Conclusion Industry funded randomised controlled trials, in the absence of statistically significant primary outcomes, are more likely to report subgroup analyses than non-industry funded trials. Industry funded trials less frequently prespecify subgroup hypotheses and less frequently test for interaction than non-industry funded trials. Subgroup analyses from industry funded trials with negative results for the primary outcome should be viewed with caution.