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National Collaborating Centre for Methods and Tools

November 2016 · Issue 202

In this issue:

Call for abstracts!

Share your EIDM story with NCCMT!

Have you incorporated evidence-informed decision making (EIDM) into your public health practice? Has a specific method or tool proven to be helpful for promoting the use of research where you work? If so, the National Collaborating Centre for Methods and Tools (NCCMT) would love to hear from you!

The NCCMT is currently collecting success stories related to EIDM in public health. Any individual or team with a story to share is encouraged to submit a 300- to 500-word abstract describing their efforts to incorporate EIDM into public health practice and/or policy. 

Details about abstract submission can be found here.

Selected abstracts will be developed into 3–5  page stories and included in an online casebook that will help illustrate what EIDM looks like across Canada.

Authors of selected stories will be eligible to participate in a proposed panel presentation at CPHA 2017, including up to $1,500 in sponsorship toward attendance. Selected stories will also be included in an article to be submitted to the Canadian Journal of Public Health.

The deadline for abstract submission is Friday, December 23, 2016.

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Upcoming survey of public health practitioners

A survey of evidence-informed public health services in Canada

Starting in mid-November, the National Collaborating Centre for Methods and Tools (NCCMT) will be administering a survey regarding the services Canadian public health decision makers use to inform their decisions with research evidence. 

The online questionnaire will be open to all public health practitioners, with participants being eligible for a prize draw.

Watch for an update in next week’s bulletin!

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New from Public Health+

Household interventions for preventing domestic lead exposure in children.

BACKGROUND: Lead poisoning is associated with physical, cognitive and neurobehavioural impairment in children, and trials have tested many household interventions to prevent lead exposure. This is an update of the original review, first published in 2008. OBJECTIVES: To assess the effects of household interventions for preventing or reducing lead exposure in children, as measured by improvements in cognitive and neurobehavioural development, reductions in blood lead levels and reductions in household dust lead levels. SEARCH METHODS: In May 2016 we searched CENTRAL, Ovid MEDLINE, Embase, nine other databases and two trials registers: the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov. We also checked the reference lists of relevant studies and contacted experts to find unpublished studies. SELECTION CRITERIA: Randomised controlled trials (RCTs) and quasi-RCTs of household educational or environmental interventions, or combinations of interventions to prevent lead exposure in children (from birth to 18 years of age), where investigators reported at least one standardised outcome measure. DATA COLLECTION AND ANALYSIS: Two authors independently reviewed all eligible studies for inclusion, assessed risk of bias and extracted data. We contacted trialists to obtain missing information. We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS: We included 14 studies involving 2643 children: 13 RCTs (involving 2565 children) and one quasi-RCT (involving 78 children). Children in all studies were under six years of age. Thirteen studies took place in urban areas of North America, and one was in Australia. Most studies were in areas with low socioeconomic status. Girls and boys were equally represented in all studies. The duration of the intervention ranged from 3 months to 24 months in 12 studies, while 2 studies performed interventions on a single occasion. Follow-up periods ranged from 6 months to 48 months. Three RCTs were at low risk of bias in all assessed domains. We rated two RCTs and one quasi-RCT as being at high risk of selection bias and six RCTs as being at high risk of attrition bias. For educational interventions, we rated the quality of evidence to be high for continuous blood lead levels and moderate for all other outcomes. For environmental interventions, we assessed the quality of evidence as moderate to low. National or international research grants or governments funded 12 studies, while the other 2 did not report their funding sources.No studies reported on cognitive or neurobehavioural outcomes. No studies reported on adverse events in children. All studies reported blood lead level outcomes.We put studies into subgroups according to their intervention type. We performed meta-analyses of both continuous and dichotomous data for subgroups where appropriate. Educational interventions were not effective in reducing blood lead levels (continuous: mean difference (MD) 0.02, 95% confidence interval (CI) -0.09 to 0.12, I(2) = 0%; 5 studies; N = 815; high quality evidence (log transformed); dichotomous >/= 10.0 microg/dL (>/= 0.48 micromol/L): risk ratio (RR) 1.02, 95% CI 0.79 to 1.30; I(2) = 0%; 4 studies; N = 520; moderate quality evidence; dichotomous >/= 15.0 microg/dL (>/= 0.72 micromol/L): RR 0.60, 95% CI 0.33 to 1.09; I(2) = 0%; 4 studies; N = 520; moderate quality evidence). Meta-analysis for the dust control subgroup also found no evidence of effectiveness on blood lead levels (continuous: MD -0.15, 95% CI -0.42 to 0.11; I(2) = 90%; 3 studies; N = 298; low quality evidence (log transformed); dichotomous >/= 10.0 microg/dL (>/= 0.48 micromol/L): RR 0.93, 95% CI 0.73 to 1.18; I(2) = 0; 2 studies; N = 210; moderate quality evidence; dichotomous >/= 15.0 microg/dL (>/= 0.72 micromol/L): RR 0.86, 95% CI 0.35 to 2.07; I(2) = 56%; 2 studies; N = 210; low quality evidence). After adjusting the dust control subgroup for clustering in meta-analysis, we found no evidence of effectiveness. We could not pool the studies using soil abatement (removal and replacement) and combination intervention groups in a meta-analysis due to substantial differences between studies, and generalisability or reproducibility of the results from these studies is unknown. Therefore, there is currently insufficient evidence to clarify whether soil abatement or a combination of interventions reduces blood lead levels. AUTHORS` CONCLUSIONS: Based on current knowledge, household educational interventions are ineffective in reducing blood lead levels in children as a population health measure. Dust control interventions may lead to little or no difference in blood lead levels (the quality of evidence was moderate to low, meaning that future research is likely to change these results). There is currently insufficient evidence to draw conclusions about the effectiveness of soil abatement or combination interventions. No study reported on cogni

The full text may be available from PubMed

Insulin secretagogues for prevention or delay of type 2 diabetes mellitus and its associated complications in persons at increased risk for the development of type 2 diabetes mellitus.

BACKGROUND: The projected rise in the incidence of type 2 diabetes mellitus (T2DM) could develop into a substantial health problem worldwide. Whether insulin secretagogues (sulphonylureas and meglitinide analogues) are able to prevent or delay T2DM and its associated complications in people at risk for the development of T2DM is unknown. OBJECTIVES: To assess the effects of insulin secretagogues on the prevention or delay of T2DM and its associated complications in people with impaired glucose tolerance, impaired fasting blood glucose, moderately elevated glycosylated haemoglobin A1c (HbA1c) or any combination of these. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, Embase, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform, and the reference lists of systematic reviews, articles and health technology assessment reports. We asked investigators of the included trials for information about additional trials. The date of the last search of all databases was April 2016. SELECTION CRITERIA: We included randomised controlled trials (RCTs) with a duration of 12 weeks or more comparing insulin secretagogues with any pharmacological glucose-lowering intervention, behaviour-changing intervention, placebo or no intervention in people with impaired fasting glucose, impaired glucose tolerance, moderately elevated HbA1c or combinations of these. DATA COLLECTION AND ANALYSIS: Two review authors read all abstracts and full-text articles/records, assessed quality and extracted outcome data independently. One review author extracted data which were checked by a second review author. We resolved discrepancies by consensus or the involvement of a third review author. For meta-analyses we used a random-effects model with investigation of risk ratios (RRs) for dichotomous outcomes and mean differences (MDs) for continuous outcomes, using 95% confidence intervals (CIs) for effect estimates. We carried out trial sequential analyses (TSAs) for all outcomes that could be meta-analysed. We assessed the overall quality of the evidence by using the GRADE instrument. MAIN RESULTS: We included six RCTs with 10,018 participants; 4791 participants with data on allocation to intervention groups were randomised to a second- or third-generation sulphonylurea or a meglitinide analogue as monotherapy and 29 participants were randomised to a second-generation sulphonylurea plus metformin. Three trials investigated a second-generation sulphonylurea, two trials investigated a third-generation sulphonylurea and one trial a meglitinide analogue. A total of 4873 participants with data on allocation to control groups were randomised to a comparator group; 4820 participants were randomised to placebo, 23 to diet and exercise, and 30 participants to metformin monotherapy. One RCT of nateglinide contributed 95% of all participants. The duration of the intervention varied from six months to five years. We judged none of the included trials as at low risk of bias for all `Risk of bias` domains.All-cause and cardiovascular mortality following sulphonylurea (glimepiride) treatment were rarely observed (very low-quality evidence). The RR for incidence of T2DM comparing glimepiride monotherapy with placebo was 0.75; 95% CI 0.54 to 1.04; P = 0.08; 2 trials; 307 participants; very low-quality evidence. One of the trials reporting on the incidence of T2DM did not define the diagnostic criteria used. The other trial diagnosed T2DM as two consecutive fasting blood glucose values >/= 6.1 mmol/L. TSA showed that only 4.5% of the diversity-adjusted required information size was accrued so far. No trial reported data on serious adverse events, non-fatal myocardial infarction (MI), non-fatal stroke, congestive heart failure (HF), health-related quality of life or socioeconomic effects.One trial with a follow-up of five years compared a meglitinide analogue (nateglinide) with placebo. A total of 310/4645 (6.7%) participants allocated to nateglinide died compared with 312/4661 (6.7%) participants allocated to placebo (hazard ratio (HR) 1.00; 95% CI 0.85 to 1.17; P = 0.98; moderate-quality evidence). The two main criteria for diagnosing T2DM were a fasting plasma glucose level >/= 7.0 mmol/L or a 2-hour post challenge glucose >/= 11.1 mmol/L. T2DM developed in 1674/4645 (36.0%) participants in the nateglinide group and in 1580/4661 (33.9%) in the placebo group (HR 1.07; 95% CI 1.00 to 1.15; P = 0.05; moderate-quality evidence). One or more serious adverse event was reported in 2066/4602 (44.9%) participants allocated to nateglinide compared with 2089/4599 (45.6%) participants allocated to placebo. A total of 126/4645 (2.7%) participants allocated to nateglinide died because of cardiovascular disease compared with 118/4661 (2.5%) participants allocated to placebo (HR 1.07; 95% CI 0.83 to 1.38; P = 0.60; moderate-quality evidence). Comparing participants receiving nateg

The full text may be available from PubMed

Nasal decongestants in monotherapy for the common cold.

BACKGROUND: Many treatments for the common cold exist and are sold over-the-counter. Nevertheless, evidence on the effectiveness and safety of nasal decongestants is limited. OBJECTIVES: To assess the efficacy, and short- and long-term safety, of nasal decongestants used in monotherapy to alleviate symptoms of the common cold in adults and children. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 6, June 2016), which contains the Cochrane Acute Respiratory Infections (ARI) Specialised Register, MEDLINE (1946 to July 2016), Embase (2010 to 15 July 2016), CINAHL (1981 to 15 July 2016), LILACS (1982 to July 2016), Web of Science (1955 to July 2016) and clinical trials registers. SELECTION CRITERIA: Randomised controlled trials (RCTs) and cluster-RCTs investigating the effectiveness and adverse effects of nasal decongestants compared with placebo for treating the common cold in adults and children. We excluded quasi-RCTs. DATA COLLECTION AND ANALYSIS: Three review authors independently extracted and summarised data on subjective measures of nasal congestion, overall patient well-being score, objective measures of nasal airway resistance, adverse effects and general recovery. One review author acted as arbiter in cases of disagreement. We categorised trials as single and multi-dose and analysed data both separately and together. We also analysed studies using an oral or topical nasal decongestant separately and together. MAIN RESULTS: We included 15 trials with 1838 participants. Fourteen studies included adult participants only (aged 18 years and over). In six studies the intervention was a single dose and in nine studies multiple doses were used. Nine studies used pseudoephedrine and three studies used oxymetazoline. Other decongestants included phenylpropanolamine, norephedrine and xylometazoline. Phenylpropanolamine (or norephedrine) is no longer available on the market therefore we did not include the results of these studies in the meta-analyses. Eleven studies used oral decongestants; four studies used topical decongestants.Participants were included after contracting the common cold. The duration of symptoms differed among studies; in 10 studies participants had symptoms for less than three days, in three studies symptoms were present for less than five days, one study counted the number of colds over one year, and one study experimentally induced the common cold. In the single-dose studies, the effectiveness of a nasal decongestant was measured on the same day, whereas the follow-up in multi-dose studies ranged between one and 10 days.Most studies were conducted in university settings (N = eight), six at a specific university common cold centre. Three studies were conducted at a university in collaboration with a hospital and two in a hospital only setting. In two studies the setting was unclear.There were large differences in the reporting of outcomes and the reporting of methods in most studies was limited. Therefore, we judged most studies to be at low or unclear risk of bias. Pooling was possible for a limited number of studies only; measures of effect are expressed as standardised mean differences (SMDs). A positive SMD represents an improvement in congestion. There is no defined minimal clinically important difference for measures of subjective improvement in nasal congestion, therefore we used the SMDs as a guide to assess whether an effect was small (0.2 to 0.49), moderate (0.5 to 0.79) or large (>/= 0.8).Single-dose decongestant versus placebo: 10 studies compared a single dose of nasal decongestant with placebo and their effectiveness was tested between 15 minutes and 10 hours after dosing. Seven of 10 studies reported subjective symptom scores for nasal congestion; none reported overall patient well-being. However, pooling was not possible due to the large diversity in the measurement and reporting of symptoms of congestion. Two studies recorded adverse events. Both studies used an oral decongestant and each of them showed that there was no statistical difference between the number of adverse events in the treatment group versus the placebo group.Multi-dose decongestant versus placebo: nine studies compared multiple doses of nasal decongestants with placebo, but only five reported on the primary outcome, subjective symptom scores for nasal congestion. Only one study used a topical decongestant; none reported overall patient well-being. Subjective measures of congestion were significantly better for the treatment group compared with placebo approximately three hours after the last dose (SMD 0.49, 95% confidence interval (CI) 0.07 to 0.92; P = 0.02; GRADE: low-quality evidence). However, the SMD of 0.49 only indicates a small clinical effect. Pooling was based on two studies, one oral and one topical, therefore we were unable to assess the effects of oral and topical decongestants separately. Seven studies reported adverse events (six ora

The full text may be available from PubMed

Brief Primary Care Obesity Interventions: A Meta-analysis.

CONTEXT: Although practice guidelines suggest that primary care providers working with children and adolescents incorporate BMI surveillance and counseling into routine practice, the evidence base for this practice is unclear. OBJECTIVE: To determine the effect of brief, primary care interventions for pediatric weight management on BMI. DATA SOURCES: Medline, CENTRAL, Embase, PsycInfo, and CINAHL were searched for relevant publications from January 1976 to March 2016 and cross-referenced with published studies. STUDY SELECTION: Eligible studies were randomized controlled trials and quasi-experimental studies that compared the effect of office-based primary care weight management interventions to any control intervention on percent BMI or BMI z scores in children aged 2 to 18 years. DATA EXTRACTION: Two reviewers independently screened sources, extracted data on participant, intervention, and study characteristics, z-BMI/percent BMI, harms, and study quality using the Cochrane and Newcastle-Ottawa risk of bias tools. RESULTS: A random effects model was used to pool the effect size across eligible 10 randomized controlled trials and 2 quasi-experimental studies. Compared with usual care or control treatment, brief interventions feasible for primary care were associated with a significant but small reduction in BMI z score (-0.04, [95% confidence interval, -0.08 to -0.01]; P = .02) and a nonsignificant effect on body satisfaction (standardized mean difference 0.00, [95% confidence interval, -0.21 to 0.22]; P = .98). LIMITATIONS: Studies had methodological limitations, follow-up was brief, and adverse effects were not commonly measured. CONCLUSIONS: BMI surveillance and counseling has a marginal effect on BMI, highlighting the need for revised practice guidelines and the development of novel approaches for providers to address this problem.

The full text may be available from PubMed

Lack of Evidence Linking Calcium With or Without Vitamin D Supplementation to Cardiovascular Disease in Generally Healthy Adults: A Clinical Guideline From the National Osteoporosis Foundation and the American Society for Preventive Cardiology.

Description: Calcium is the dominant mineral present in bone and a shortfall nutrient in the American diet. Supplements have been recommended for persons who do not consume adequate calcium from their diet as a standard strategy for the prevention of osteoporosis and related fractures. Whether calcium with or without vitamin D supplementation is beneficial or detrimental to vascular health is not known. Methods: The National Osteoporosis Foundation and American Society for Preventive Cardiology convened an expert panel to evaluate the effects of dietary and supplemental calcium on cardiovascular disease based on the existing peer-reviewed scientific literature. The panel considered the findings of the accompanying updated evidence report provided by an independent evidence review team at Tufts University. Recommendation: The National Osteoporosis Foundation and American Society for Preventive Cardiology adopt the position that there is moderate-quality evidence (B level) that calcium with or without vitamin D intake from food or supplements has no relationship (beneficial or harmful) to the risk for cardiovascular and cerebrovascular disease, mortality, or all-cause mortality in generally healthy adults at this time. In light of the evidence available to date, calcium intake from food and supplements that does not exceed the tolerable upper level of intake (defined by the National Academy of Medicine as 2000 to 2500 mg/d) should be considered safe from a cardiovascular standpoint.

The full text may be available from PubMed

Interventions to reduce harm from continued tobacco use.

BACKGROUND: Although smoking cessation is currently the only guaranteed way to reduce the harm caused by tobacco smoking, a reasonable secondary tobacco control approach may be to try and reduce the harm from continued tobacco use amongst smokers unable or unwilling to quit. Possible approaches to reduce the exposure to toxins from smoking include reducing the amount of tobacco used, and using less toxic products, such as pharmaceutical, nicotine and potential reduced-exposure tobacco products (PREPs), as an alternative to cigarettes. OBJECTIVES: To assess the effects of interventions intended to reduce the harm to health of continued tobacco use, we considered the following specific questions: do interventions intended to reduce harm have an effect on long-term health status?; do they lead to a reduction in the number of cigarettes smoked?; do they have an effect on smoking abstinence?; do they have an effect on biomarkers of tobacco exposure?; and do they have an effect on biomarkers of damage caused by tobacco? SEARCH METHODS: We searched the Cochrane Tobacco Addiction Group Trials Register (CRS) on the 21st October 2015, using free-text and MeSH terms for harm reduction, smoking reduction and cigarette reduction. SELECTION CRITERIA: Randomized or quasi-randomized controlled trials of interventions to reduce the amount smoked, or to reduce harm from smoking by means other than cessation. We include studies carried out in smokers with no immediate desire to quit all tobacco use. Primary outcomes were change in cigarette consumption, smoking cessation and any markers of damage or benefit to health, measured at least six months from the start of the intervention. DATA COLLECTION AND ANALYSIS: We assessed study eligibility for inclusion using standard Cochrane methods. We pooled trials with similar interventions and outcomes (> 50% reduction in cigarettes a day (CPD) and long-term smoking abstinence), using fixed-effect models. Where it was not possible to meta-analyse data, we summarized findings narratively. MAIN RESULTS: Twenty-four trials evaluated interventions to help those who smoke to cut down the amount smoked or to replace their regular cigarettes with PREPs, compared to placebo, brief intervention, or a comparison intervention. None of these trials directly tested whether harm reduction strategies reduced the harms to health caused by smoking. Most trials (14/24) tested nicotine replacement therapy (NRT) as an intervention to assist reduction. In a pooled analysis of eight trials, NRT significantly increased the likelihood of reducing CPD by at least 50% for people using nicotine gum or inhaler or a choice of product compared to placebo (risk ratio (RR) 1.75, 95% confidence interval (CI) 1.44 to 2.13; 3081 participants). Where average changes from baseline were compared for different measures, carbon monoxide (CO) and cotinine generally showed smaller reductions than CPD. Use of NRT versus placebo also significantly increased the likelihood of ultimately quitting smoking (RR 1.87, 95% CI 1.43 to 2.44; 8 trials, 3081 participants; quality of the evidence: low). Two trials comparing NRT and behavioural support to brief advice found a significant effect on reduction, but no significant effect on cessation. We found one trial investigating each of the following harm reduction intervention aids: bupropion, varenicline, electronic cigarettes, snus, plus another of nicotine patches to facilitate temporary abstinence. The evidence for all five intervention types was therefore imprecise, and it is unclear whether or not these aids increase the likelihood of smoking reduction or cessation. Two trials investigating two different types of behavioural advice and instructions on reducing CPD also provided imprecise evidence. Therefore, the evidence base for this comparison is inadequate to support the use of these types of behavioural advice to reduce smoking. Four studies of PREPs (cigarettes with reduced levels of tar, carbon and nicotine, and in one case delivered using an electronically-heated cigarette smoking system) showed some reduction in exposure to some toxicants, but it is unclear whether this would substantially alter the risk of harm. We judged the included studies to be generally at a low or unclear risk of bias; however, there were some ratings of high risk, due to a lack of blinding and the potential for detection bias. Using the GRADE system, we rated the overall quality of the evidence for our cessation outcomes as `low` or `very low`, due to imprecision and indirectness. A `low` grade means that further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. A `very low` grade means we are very uncertain about the estimate. AUTHORS` CONCLUSIONS: People who do not wish to quit can be helped to cut down the number of cigarettes they smoke and to quit smoking in the long term, using NRT, despite original inte

The full text may be available from PubMed

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Upcoming webinar from NCCMT

Spotlight on Methods and Tools webinar: NCCMT Resources Mapped to the Core Competencies for Public Health

November 23, 2016
1:00 p.m. – 2:30 p.m. (ET)

What knowledge, skills and attitudes do you need to be a successful public health practitioner?

The Public Health Agency of Canada (PHAC) has outlined what they call the “basic building blocks of public health education and professional development” in their Core Competencies.

We have created a new tool on our website to help busy practitioners find the many resources available from the NCCMT that can support PHAC’s Core Competencies for Public Health in Canada. This tool helps individuals and organizations find NCCMT resources related to each competency so you can plan professional development activities tailored to your own needs or those of your team.

More on PHAC’s Core Competencies for Public Health in Canada can be found on the PHAC website.

Join us to learn more!

Click here to register.

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Upcoming webinar from HealthEvidence.org

Interventions for preventing elder abuse: What's the evidence?

November 15, 2016
1:00 p.m. – 2:30 p.m. (ET)

Join Philip Baker, Australia Regional Director APACPH, School of Public Health and Social Work Queensland University of Technology, as he discusses the findings of his team’s systematic review of the effectiveness of interventions for preventing elder abuse in the home, in institutions and in community settings.

Click here to register.

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Highlight from the Registry

Need to create a short evidence briefing? Want to compare cost-effectiveness of different options?

See this method for developing evidence briefings!

Authors Chambers and Wilson (2012) have developed a framework for writing an evidence briefing using different types of evidence, including information on local resources, cost-effectiveness, barriers and facilitators of change, local contextual information, etc. There is a checklist and sample evidence briefing to help users develop briefings, and an evaluation survey to improve the process of developing the briefing.

To learn more, see our summary: Evidence briefings from systematic reviews

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Past issues of the Round-up are available online: Weekly Digest Archive
NCCMT is funded by the Public Health Agency of Canada and affiliated with McMaster University.
Production of this newsletter has been made possible through a financial contribution from the Public Health Agency of Canada.
The views expressed herein do not necessarily represent the views of the Public Health Agency of Canada.
Contact us at nccmt@mcmaster.ca or www.nccmt.ca.